Basic Information
| Provider Information | |||||||||
| NPI: | 1497255129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | MAKALA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 PACIFIC AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252587141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 PACIFIC AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252612000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 00003894 | WA | N | 106S00000X | RBT-17-39493 | WA | N | 103K00000X | 1-20-43540 | WA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-20-43540 | 01 | WA | BEHAVIOR ANALYST CERTIFICATION BOARD | OTHER | BA61093000 | 01 | WA | DEPARTMENT OF HEALTH | OTHER |