Healthcare Provider Details

I. General information

NPI: 1164835989
Provider Name (Legal Business Name): MOMENTUM BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 24TH AVE E
SEATTLE WA
98112-2606
US

IV. Provider business mailing address

1801 E JEFFERSON ST
SEATTLE WA
98122-5743
US

V. Phone/Fax

Practice location:
  • Phone: 206-552-6724
  • Fax:
Mailing address:
  • Phone: 206-552-6724
  • 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 Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. NEILL DORN
Title or Position: MEMBER
Credential: BCBA
Phone: 206-552-6724