Provider Demographics
NPI:1386195279
Name:LILAC CITY BEHAVIORAL SERVICES, PLLC
Entity type:Organization
Organization Name:LILAC CITY BEHAVIORAL SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:STAN
Authorized Official - Last Name:KALLES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA
Authorized Official - Phone:509-844-4966
Mailing Address - Street 1:318 E ROWAN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1200
Mailing Address - Country:US
Mailing Address - Phone:509-844-2429
Mailing Address - Fax:509-319-2338
Practice Address - Street 1:318 E ROWAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1200
Practice Address - Country:US
Practice Address - Phone:509-844-2429
Practice Address - Fax:509-319-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2080619Medicaid