Provider Demographics
NPI:1619211042
Name:IMAGINE BEHAVIORAL & DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:IMAGINE BEHAVIORAL & DEVELOPMENTAL SERVICES
Other - Org Name:SL START & ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-857-9041
Mailing Address - Street 1:1575 ALLOUEZ AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5639
Mailing Address - Country:US
Mailing Address - Phone:920-857-9041
Mailing Address - Fax:920-857-3366
Practice Address - Street 1:5709 W SUNSET HWY STE 101
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-9446
Practice Address - Country:US
Practice Address - Phone:509-209-2739
Practice Address - Fax:920-857-3366
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARAVEL AUTISM HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-26
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty