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General NPI Number Information
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NPI Number | 1144386236
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Entity Type | Organization
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Legal Business Name | EAST LAKE PSYCHOLOGICAL SERVICES, PS
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Dates
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Enumeration Date | 12/31/2006
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Last Update Date | 01/19/2011
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Provider Practice Location Address
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Address Line | 4026 NE 55TH ST SUITE D
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City | SEATTLE
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State | WA
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Zip | 98105-2262
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Country | US
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Telephone | 425-785-5887
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Fax |
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Provider Business Mailing Address
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Address Line | 4026 NE 55TH ST SUITE D
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City | SEATTLE
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State | WA
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Zip | 98105-2262
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Country | US
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Telephone | 425-785-5887
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. YIE -WEN YUAN KUAN
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Credential | PH.D.
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Telephone | 425-785-5887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY 1728
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License Number State | WA
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