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General NPI Number Information
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NPI Number | 1952633737
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Entity Type | Organization
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Legal Business Name | EASTSIDE BEHAVIORAL MEDICINE
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Dates
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Enumeration Date | 02/04/2010
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Last Update Date | 02/04/2010
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Provider Practice Location Address
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Address Line | 1601 114TH AVE SE SUITE 145
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City | BELLEVUE
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State | WA
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Zip | 98004-6950
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Country | US
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Telephone | 425-454-3110
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Fax | 425-283-0486
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Provider Business Mailing Address
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Address Line | 1601 114TH AVE SE SUITE 145
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City | BELLEVUE
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State | WA
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Zip | 98004-6950
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Country | US
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Telephone | 425-454-3110
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Fax | 425-283-0486
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Authorized Official
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Title or Position | OWNER
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Name | DR. DARLA CAPETILLO
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Credential | PHD
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Telephone | 425-454-3110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 602-967-118
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License Number State | WA
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