Provider Demographics
NPI:1275020547
Name:PACIFIC NORTHWEST BEHAVIOR, LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST BEHAVIOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KOURTNEY
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:LBA, BCBA
Authorized Official - Phone:509-995-3388
Mailing Address - Street 1:PO BOX 8344
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-0344
Mailing Address - Country:US
Mailing Address - Phone:509-995-3388
Mailing Address - Fax:509-321-4350
Practice Address - Street 1:1209 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-4101
Practice Address - Country:US
Practice Address - Phone:509-995-3388
Practice Address - Fax:509-321-4350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2100815Medicaid