Healthcare Provider Details

I. General information

NPI: 1669042594
Provider Name (Legal Business Name): MARIAH CORNWALL LBA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 E SPRAGUE AVE STE A
SPOKANE VALLEY WA
99206-5135
US

IV. Provider business mailing address

11530 E SPRAGUE AVE STE A
SPOKANE VALLEY WA
99206-5135
US

V. Phone/Fax

Practice location:
  • Phone: 509-720-8138
  • Fax: 509-408-5377
Mailing address:
  • Phone: 509-720-8138
  • Fax: 509-408-5377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA.BA.70186790
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: