1295059418 NPI number — BEHAVIORAL THERAPY AND CONSULTATION VA LLC

Table of content: (NPI 1295059418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295059418 NPI number — BEHAVIORAL THERAPY AND CONSULTATION VA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEHAVIORAL THERAPY AND CONSULTATION VA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1295059418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12359 SUNRISE VALLEY DR
Provider Second Line Business Mailing Address:
220
Provider Business Mailing Address City Name:
RESTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20191-3462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-251-1859
Provider Business Mailing Address Fax Number:
703-441-7814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3073 ANTRIM CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUMFRIES
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22026-3319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-251-1859
Provider Business Practice Location Address Fax Number:
703-441-7814
Provider Enumeration Date:
03/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
EAKIN
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BEHAVIOR ANALYST
Authorized Official Telephone Number:
571-251-1859

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X , with the licence number:  1-09-6402 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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