1700356078 NPI number — LYDIA KAY PEREZ LICSWA

Table of content: LYDIA KAY PEREZ LICSWA (NPI 1700356078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700356078 NPI number — LYDIA KAY PEREZ LICSWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ
Provider First Name:
LYDIA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSWA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARLSON
Provider Other First Name:
LYDIA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700356078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7522 S PALOUSE HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99223-2016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-761-9415
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 N PINES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99206-5225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-892-1100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2018

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: 1041C0700X , with the licence number:  SC61589218 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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