Healthcare Provider Details

I. General information

NPI: 1881503944
Provider Name (Legal Business Name): PHOENIX AZRIEL WATTAM RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 STEWART ST STE 300
SEATTLE WA
98101-1257
US

IV. Provider business mailing address

5142 BYERS RD
FERNDALE WA
98248-8928
US

V. Phone/Fax

Practice location:
  • Phone: 360-296-0439
  • Fax:
Mailing address:
  • Phone: 360-296-0439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2834940
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: