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General NPI Number Information
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NPI Number | 1104105816
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Entity Type | Organization
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Legal Business Name | LEAPSS AND BEYOND
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Dates
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Enumeration Date | 08/11/2011
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Last Update Date | 08/11/2011
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Provider Practice Location Address
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Address Line | 413 LINCOLN AVE STE A
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City | MUKILTEO
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State | WA
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Zip | 98275-1524
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Country | US
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Telephone | 559-314-4696
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Fax |
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Provider Business Mailing Address
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Address Line | 413 LINCOLN AVE STE A
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City | MUKILTEO
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State | WA
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Zip | 98275-1524
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Country | US
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Telephone | 559-314-4696
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Fax |
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Authorized Official
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Title or Position | CLINICALAND NEUROPSYCHOLOGIST
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Name | DR. EDWYN W ORTIZ-NANCE
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Credential | PSYD
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Telephone | 559-824-8934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PY60221926
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 103TM1800X
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Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
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License Number | PY60221926
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number | PY60221926
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License Number State | WA
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PS60221926
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License Number State | WA
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