Provider Demographics
NPI:1164835989
Name:MOMENTUM BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:MOMENTUM BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:NEILL
Authorized Official - Middle Name:
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:206-552-6724
Mailing Address - Street 1:1801 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5743
Mailing Address - Country:US
Mailing Address - Phone:206-552-6724
Mailing Address - Fax:
Practice Address - Street 1:2317 24TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-2606
Practice Address - Country:US
Practice Address - Phone:206-552-6724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty