Healthcare Provider Details

I. General information

NPI: 1659841831
Provider Name (Legal Business Name): IMPACT BEHAVIOR CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W GREENWAY BLVD
FALLS CHURCH VA
22046-4005
US

IV. Provider business mailing address

108 W GREENWAY BLVD
FALLS CHURCH VA
22046-4005
US

V. Phone/Fax

Practice location:
  • Phone: 703-399-1786
  • Fax:
Mailing address:
  • Phone: 703-399-1786
  • 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 Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL RUDY
Title or Position: FOUNDER
Credential:
Phone: 703-399-1786