Provider Demographics
NPI:1548564610
Name:EASTHAM, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:EASTHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:EASTHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:4041 GLORIA LN
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-1733
Mailing Address - Country:US
Mailing Address - Phone:360-676-8753
Mailing Address - Fax:
Practice Address - Street 1:809 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5221
Practice Address - Country:US
Practice Address - Phone:360-788-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003228225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist