Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | WA | |
N | 106E00000X | Assistant Behavior Analyst | WA | |
N | 106S00000X | Behavior Technician | WA |
NPI | 1104398924 |
---|---|
Provider Name | Matthew Sandstrom |
First Address | Renton, WA 98056-4097 |
Second Address | Renton, WA 98056-4097 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2018 |
Last Update Date | 18/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
111524501 | (05) | WA |