Provider Demographics
NPI:1164206181
Name:PRIBNOW, CARTER RICHARD
Entity Type:Individual
Prefix:
First Name:CARTER
Middle Name:RICHARD
Last Name:PRIBNOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 128TH ST NW
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-7020
Mailing Address - Country:US
Mailing Address - Phone:406-465-8688
Mailing Address - Fax:
Practice Address - Street 1:1323 128TH ST NW
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-7020
Practice Address - Country:US
Practice Address - Phone:406-465-8688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWDL1526CB13B106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician