Provider Demographics
NPI:1255865135
Name:BAYSIDE AUTISM THERAPIES, LLC
Entity Type:Organization
Organization Name:BAYSIDE AUTISM THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:TARVER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, SLP
Authorized Official - Phone:425-429-4793
Mailing Address - Street 1:1104 DONOVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7325
Mailing Address - Country:US
Mailing Address - Phone:425-429-4793
Mailing Address - Fax:
Practice Address - Street 1:1104 DONOVAN AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7325
Practice Address - Country:US
Practice Address - Phone:425-429-4793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA11520651251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2065537Medicaid