MEDICARE: INTEGRATED HEALTH AND BEHAVIOR, PLLC

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	2084P0804X	Child & Adolescent Psychiatry Physician	MD00047831	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1487664603	OTHER	WA	NPI FOR INDIVIDUAL

General Provider Information

NPI Number	:	1902129638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED HEALTH AND BEHAVIOR, PLLC

Provider Business Mailing Address
First Line	:	2310 N MOLTER RD STE 105
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-8621
Country	:	US
Telephone Number	:	509-891-7867
Fax Number	:	509-922-0984

Provider Business Practice Location Address
First Line	:	2310 N MOLTER RD STE 105
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-8621
Country	:	US
Telephone Number	:	509-891-7867
Fax Number	:	509-922-0984

Authorized Official
Title or Position	:	TREASURER/OFFICE MANAGER
Name	:	TAMARA FISHER WIRTHLIN
Credential	:	JD
Telephone Number	:	509-891-7867

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	12/08/2015

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