Healthcare Provider Details

I. General information

NPI: 1043619638
Provider Name (Legal Business Name): IMAGINE BEHAVIORAL AND DEVELOPMENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 S TACOMA WAY
TACOMA WA
98499-4456
US

IV. Provider business mailing address

901 N MONROE ST STE 200
SPOKANE WA
99201-2148
US

V. Phone/Fax

Practice location:
  • Phone: 253-682-0320
  • Fax:
Mailing address:
  • Phone: 509-328-2740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberCG60490737
License Number StateWA

VIII. Authorized Official

Name: NIKKI PAGEL
Title or Position: CREDENTIALING
Credential:
Phone: 509-209-2696