=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730822743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARAVEL AUTISM HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2022
-----------------------------------------------------
Last Update Date | 04/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1008 WARREN AVE
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98337-1557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-219-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1008 WARREN AVE
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98337-1557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-219-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIOR TECHNICIAN
-----------------------------------------------------
Name | AMANDA NICOLE GEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-219-8757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------