Healthcare Provider Details

I. General information

NPI: 1326546235
Provider Name (Legal Business Name): FORMATIONS BEHAVIOR THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 03/11/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6409 E MILL PLAIN BLVD
VANCOUVER WA
98661-7454
US

IV. Provider business mailing address

9700 NE 21ST PL
VANCOUVER WA
98665-5730
US

V. Phone/Fax

Practice location:
  • Phone: 360-718-8376
  • Fax: 833-972-1949
Mailing address:
  • Phone: 360-518-6249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number604176297
License Number StateWA

VIII. Authorized Official

Name: ELLIS GRANT THOMPSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 360-718-8376