MEDICARE: DOMINION ABA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	1654-07-004	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790045334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION ABA

Provider Business Mailing Address
First Line	:	5408 CHAMBERLAYNE RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-2407
Country	:	US
Telephone Number	:	804-285-9838
Fax Number	:	804-285-9839

Provider Business Practice Location Address
First Line	:	5408 CHAMBERLAYNE RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-2407
Country	:	US
Telephone Number	:	804-285-9838
Fax Number	:	804-285-9839

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. GEORGE PULLIAM JR.
Credential	:	MS
Telephone Number	:	804-285-9838

Provider Enumeration Date	:	05/16/2012
Last Update Date	:	05/16/2012

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Directions to “DOMINION ABA ” Practice Location

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