Healthcare Provider Details

I. General information

NPI: 1023628526
Provider Name (Legal Business Name): KAITLIN JOYCE AGOSTA BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2020
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 CAPITOL BLVD SE
TUMWATER WA
98501-5205
US

IV. Provider business mailing address

6330 CAPITOL BLVD SE
TUMWATER WA
98501-5205
US

V. Phone/Fax

Practice location:
  • Phone: 360-456-2237
  • Fax:
Mailing address:
  • Phone: 360-456-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA61603313
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberLABA.AB.61493617
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: