Healthcare Provider Details

I. General information

NPI: 1063192607
Provider Name (Legal Business Name): IMAGINE THAT THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 BELLE HAVEN ROAD, #410
ALEXANDRIA VA
22307
US

IV. Provider business mailing address

1451 BELLE HAVEN RD STE 410
ALEXANDRIA VA
22307-1201
US

V. Phone/Fax

Practice location:
  • Phone: 917-882-8413
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JOANNA BOUBOULIS
Title or Position: FOUNDER
Credential:
Phone: 917-882-8413