=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356747034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE THERAPY ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2014
-----------------------------------------------------
Last Update Date | 11/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 NW JUNIPER ST SUITE 100
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-830-0025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 NW JUNIPER ST SUITE 100
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-830-0025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. CAROL J. KING
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 425-830-0025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT00000754
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------