Provider Demographics
NPI:1154835841
Name:COLUMBIA RIVER GORGE BEHAVIOR SERVICES, LLC
Entity Type:Organization
Organization Name:COLUMBIA RIVER GORGE BEHAVIOR SERVICES, LLC
Other - Org Name:GORGE BEHAVIOR SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTILLANO
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:509-396-6592
Mailing Address - Street 1:185 NE SNOHOMISH AVE UNIT 724
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-0160
Mailing Address - Country:US
Mailing Address - Phone:509-396-6592
Mailing Address - Fax:509-834-7266
Practice Address - Street 1:185 NE SNOHOMISH AVE UNIT 724
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-0160
Practice Address - Country:US
Practice Address - Phone:509-396-6592
Practice Address - Fax:509-834-7266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty