Provider Demographics
NPI:1992293062
Name:BACCUS, JULIA ANN
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:ANN
Last Name:BACCUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 LILLY RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3091
Mailing Address - Country:US
Mailing Address - Phone:360-456-2237
Mailing Address - Fax:
Practice Address - Street 1:6330 CAPITOL BLVD SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-5205
Practice Address - Country:US
Practice Address - Phone:360-915-6934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
WABA61219525103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician