Provider Demographics
NPI:1902808942
Name:EASTSIDE CHILDREN'S THERAPY
Entity Type:Organization
Organization Name:EASTSIDE CHILDREN'S THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIKTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:425-392-2346
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-0819
Mailing Address - Country:US
Mailing Address - Phone:360-893-6576
Mailing Address - Fax:360-893-6506
Practice Address - Street 1:710 NW JUNIPER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2717
Practice Address - Country:US
Practice Address - Phone:425-392-2346
Practice Address - Fax:425-392-0185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00000808225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1821EAOtherREGENCE BLUE SHIELD GRP
WA7680648Medicaid