Healthcare Provider Details

I. General information

NPI: 1679953681
Provider Name (Legal Business Name): CHRISTINE MARIE DOMSCHOT BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 S 333RD ST STE 130
FEDERAL WAY WA
98003-7357
US

IV. Provider business mailing address

3627 212TH PL SE
SAMMAMISH WA
98075-9211
US

V. Phone/Fax

Practice location:
  • Phone: 253-682-0320
  • Fax: 920-857-3366
Mailing address:
  • Phone: 505-917-5234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA60775007
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: