=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154913812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLABORATIVE BEHAVIORAL APPROACH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2021
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 2ND AVE NE
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98372-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-355-7428
-----------------------------------------------------
Fax | 360-832-1687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 866
-----------------------------------------------------
City | GRAHAM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98338-0866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-355-7428
-----------------------------------------------------
Fax | 360-832-1687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. REBECCA M SHAVER
-----------------------------------------------------
Credential | MA, LMHC, MHP
-----------------------------------------------------
Telephone | 253-355-7428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------