Provider Demographics
NPI:1659924363
Name:FASTABEND, DANIELLE DOMINIQUE (CBT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:DOMINIQUE
Last Name:FASTABEND
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 SE GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-8634
Mailing Address - Country:US
Mailing Address - Phone:360-553-9917
Mailing Address - Fax:
Practice Address - Street 1:9414 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6109
Practice Address - Country:US
Practice Address - Phone:360-892-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB0974695106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician