Provider Demographics
NPI:1275347296
Name:DER BLATTER, SHANTI NICHELLE
Entity type:Individual
Prefix:
First Name:SHANTI
Middle Name:NICHELLE
Last Name:DER BLATTER
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:ROO
Other - Middle Name:
Other - Last Name:DER BLATTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:505 BELMONT AVE E APT 905
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-6705
Mailing Address - Country:US
Mailing Address - Phone:206-829-0297
Mailing Address - Fax:
Practice Address - Street 1:11410 NE 122ND WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6945
Practice Address - Country:US
Practice Address - Phone:425-650-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician