Provider Demographics
NPI:1487136370
Name:FAUTENBERRY, CAILA (RBT)
Entity type:Individual
Prefix:
First Name:CAILA
Middle Name:
Last Name:FAUTENBERRY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2559 S WATERBURY LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4981
Mailing Address - Country:US
Mailing Address - Phone:805-668-8961
Mailing Address - Fax:208-416-6922
Practice Address - Street 1:1420 NW GILMAN BLVD STE 2604
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5394
Practice Address - Country:US
Practice Address - Phone:805-668-8961
Practice Address - Fax:208-416-6922
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60775476103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACB60775476Medicaid