Basic Information
| Provider Information | |||||||||
| NPI: | 1073864849 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BASICS NW, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 SE BLUE HERON LN | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985847658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602804414 | ||||||||
| FaxNumber: | 3605476470 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 SE BLUE HERON LN | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985847658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602804414 | ||||||||
| FaxNumber: | 3605476470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | WOODARD | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | JEFFREY | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3602804414 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MED, BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CL60302030 | WA | Y | Agencies | Community/Behavioral Health |
No ID Information.