MEDICARE: AMBRLYN SHANNON COOLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1417757378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBRLYN SHANNON COOLEY

Provider Business Mailing Address
First Line	:	600 KITSAP ST
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-5327
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 KITSAP ST
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-5327
Country	:	US
Telephone Number	:	425-275-6535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2025
Last Update Date	:	03/18/2025

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Directions to “ AMBRLYN SHANNON COOLEY ” Practice Location

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