Provider Demographics
NPI:1043619638
Name:IMAGINE BEHAVIORAL AND DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:IMAGINE BEHAVIORAL AND DEVELOPMENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:PAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-209-2696
Mailing Address - Street 1:901 N MONROE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2148
Mailing Address - Country:US
Mailing Address - Phone:509-328-2740
Mailing Address - Fax:
Practice Address - Street 1:9720 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499-4456
Practice Address - Country:US
Practice Address - Phone:253-682-0320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60490737103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty