Provider Demographics
NPI:1326658345
Name:NOONAN, JUSTIN (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:NOONAN
Suffix:
Gender:M
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3680 S CEDAR ST STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5728
Practice Address - Country:US
Practice Address - Phone:206-313-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid