Provider Demographics
NPI:1962142257
Name:FUQUA, THOMAS (M ED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:FUQUA
Suffix:
Gender:M
Credentials:M ED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8019 NE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-9604
Mailing Address - Country:US
Mailing Address - Phone:360-984-3131
Mailing Address - Fax:
Practice Address - Street 1:1622 TERMINAL DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-4953
Practice Address - Country:US
Practice Address - Phone:360-984-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA61422369103K00000X
WAAB61325252106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst