Provider Demographics
NPI:1497149140
Name:WALLY, CASSANDRA (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:WALLY
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 NE 71ST AVE UNIT 12
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-1944
Mailing Address - Country:US
Mailing Address - Phone:360-229-2029
Mailing Address - Fax:
Practice Address - Street 1:5809 NE 71ST AVE
Practice Address - Street 2:UNIT 12
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-9866
Practice Address - Country:US
Practice Address - Phone:360-229-2029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1-16-24068103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst