Healthcare Provider Details

I. General information

NPI: 1376027086
Provider Name (Legal Business Name): SOUTH PUGET SOUND ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 RIVER HEIGHTS RD
CENTRALIA WA
98531-8830
US

IV. Provider business mailing address

314 RIVER HEIGHTS RD
CENTRALIA WA
98531-8830
US

V. Phone/Fax

Practice location:
  • Phone: 360-819-8180
  • Fax:
Mailing address:
  • Phone: 360-819-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL SEAN KEITH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 360-819-8180