Provider Demographics
NPI:1992252571
Name:SUTTON, HOLLY LYNN (BS, AAC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:SUTTON
Suffix:
Gender:F
Credentials:BS, AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 TIETON DR STE C
Mailing Address - Street 2:5301 TIETON DRIVE SUITE C
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3479
Mailing Address - Country:US
Mailing Address - Phone:509-965-7100
Mailing Address - Fax:
Practice Address - Street 1:3801 KERN ROAD
Practice Address - Street 2:CHILDREN'S VILLAGE
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902
Practice Address - Country:US
Practice Address - Phone:509-574-3267
Practice Address - Fax:509-574-6710
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60672517106E00000X
WABA60828820103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2065792Medicaid
WA2065792Medicaid