Basic Information
| Provider Information | |||||||||
| NPI: | 1124455142 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEATTLE BEHAVIOR CONSULTING & THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4746 11TH AVE NE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981054657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065358876 | ||||||||
| FaxNumber: | 2064869938 | ||||||||
| Practice Location | |||||||||
| Address1: | 4746 11TH AVE NE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981054657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065358876 | ||||||||
| FaxNumber: | 2064869938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2013 | ||||||||
| LastUpdateDate: | 03/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | OBLAK | ||||||||
| AuthorizedOfficialFirstName: | MARA | ||||||||
| AuthorizedOfficialMiddleName: | KATRA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/BEHAVIOR ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 2065358876 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD, BCBA-D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1-09-5509 | N | Agencies | Community/Behavioral Health | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 2034841 | 05 | WA | MEDICAID |