1508111766 NPI number — MRS. PENNY JANE LATHUM M.ED., BCBA

Table of content: MRS. PENNY JANE LATHUM M.ED., BCBA (NPI 1508111766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508111766 NPI number — MRS. PENNY JANE LATHUM M.ED., BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATHUM
Provider First Name:
PENNY
Provider Middle Name:
JANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED., BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WADE
Provider Other First Name:
PENNY
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.ED., BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508111766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5436 232ND AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-380-3009
Provider Business Mailing Address Fax Number:
425-837-1982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3849 KLAHANIE DR SE APT 1-101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98029-5720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-380-3009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-10-7087 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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