Healthcare Provider Details

I. General information

NPI: 1124911797
Provider Name (Legal Business Name): WILLOW BEHAVIOR THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4616 SW FRONTENAC ST
SEATTLE WA
98136-1737
US

IV. Provider business mailing address

6523 CALIFORNIA AVE SW STE 19
SEATTLE WA
98136-1833
US

V. Phone/Fax

Practice location:
  • Phone: 425-345-7114
  • Fax:
Mailing address:
  • Phone: 425-345-7114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MCCULLOUGH R CHASTAIN
Title or Position: CEO
Credential:
Phone: 425-345-7114