Basic Information
| Provider Information | |||||||||
| NPI: | 1154611143 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUTISM BEHAVIORAL CONSULTING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 NE 7TH AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986854599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605243440 | ||||||||
| FaxNumber: | 3609893972 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 NE 7TH AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986854599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605243440 | ||||||||
| FaxNumber: | 3609893972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2011 | ||||||||
| LastUpdateDate: | 01/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | AUDRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIOR ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 3605243440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.ED., BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-07-3826 | 01 | BOARD CERTIFIED BEHAVIOR ANALYST | OTHER | CL60158252 | 01 | WA | WASHINGTON STATE CERTIFIED COUNSELOR | OTHER |