Healthcare Provider Details

I. General information

NPI: 1336403682
Provider Name (Legal Business Name): RICCI ALISHA GOGUEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RICCI ALISHA HAUGEN

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 E ROWAN AVE STE 201
SPOKANE WA
99207-1200
US

IV. Provider business mailing address

321 FORTUNE BLVD
MILFORD MA
01757-1750
US

V. Phone/Fax

Practice location:
  • Phone: 509-844-4966
  • Fax: 509-319-2338
Mailing address:
  • Phone: 508-478-0207
  • Fax: 508-634-6984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA60928335
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: