Provider Demographics
NPI:1487876702
Name:CAROLYN L HARESTAD
Entity type:Organization
Organization Name:CAROLYN L HARESTAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC S
Authorized Official - Phone:253-874-2599
Mailing Address - Street 1:33515 10 PL SO
Mailing Address - Street 2:BUILDING 13
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-7300
Mailing Address - Country:US
Mailing Address - Phone:253-874-2599
Mailing Address - Fax:253-874-2392
Practice Address - Street 1:33515 10 PL SO
Practice Address - Street 2:BUILDING 13
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7300
Practice Address - Country:US
Practice Address - Phone:253-874-2599
Practice Address - Fax:253-874-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7077159Medicaid
WA9042326Medicaid
WA7077167Medicaid