Healthcare Provider Details

I. General information

NPI: 1194053850
Provider Name (Legal Business Name): GINA MARIE BALLONE M.S., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 08/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11240 WAPLES MILL RD SUITE 101
FAIRFAX VA
22030-6078
US

IV. Provider business mailing address

11240 WAPLES MILL RD SUITE 101
FAIRFAX VA
22030-6078
US

V. Phone/Fax

Practice location:
  • Phone: 703-237-2219
  • Fax: 703-237-2729
Mailing address:
  • Phone: 703-237-2219
  • Fax: 703-237-2729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-03-1182
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133000063
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: