Provider Demographics
NPI:1386976280
Name:FAMILT SUPPORT AGENCY, INC.
Entity type:Organization
Organization Name:FAMILT SUPPORT AGENCY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LAVINE
Authorized Official - Suffix:
Authorized Official - Credentials:BED, RC
Authorized Official - Phone:509-443-4680
Mailing Address - Street 1:9 S WASHINGTON ST
Mailing Address - Street 2:SUITE 505
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-3719
Mailing Address - Country:US
Mailing Address - Phone:509-443-4680
Mailing Address - Fax:877-280-8502
Practice Address - Street 1:208 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1954
Practice Address - Country:US
Practice Address - Phone:509-350-5260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health