MEDICARE: GRAYDON L. AGAR BCBA

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	103K00000X	Behavior Analyst	1-03-1189	MI

General Provider Information

NPI Number	:	1578872859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRAYDON L. AGAR BCBA

Provider Business Mailing Address
First Line	:	819 VIRGINIA ST
Second Line	:	UNIT 1603
City	:	SEATTLE
State	:	WA
Zip	:	98101-4421
Country	:	US
Telephone Number	:	206-618-4673
Fax Number	:

Provider Business Practice Location Address
First Line	:	819 VIRGINIA ST
Second Line	:	UNIT 1603
City	:	SEATTLE
State	:	WA
Zip	:	98101-4421
Country	:	US
Telephone Number	:	206-618-4673
Fax Number	:

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

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	10/04/2010

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