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General NPI Number Information
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NPI Number | 1326546235
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Entity Type | Organization
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Legal Business Name | FORMATIONS BEHAVIOR THERAPY
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Dates
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Enumeration Date | 01/25/2018
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Last Update Date | 03/11/2025
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Provider Practice Location Address
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Address Line | 6409 E MILL PLAIN BLVD
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City | VANCOUVER
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State | WA
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Zip | 98661-7454
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Country | US
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Telephone | 360-718-8376
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Fax | 833-972-1949
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Provider Business Mailing Address
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Address Line | 9700 NE 21ST PL
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City | VANCOUVER
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State | WA
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Zip | 98665-5730
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Country | US
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Telephone | 360-518-6249
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ELLIS GRANT THOMPSON
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Credential |
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Telephone | 360-718-8376
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 604176297
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License Number State | WA
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