Healthcare Provider Details

I. General information

NPI: 1093264657
Provider Name (Legal Business Name): BEHAVIORAL MOMENTUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 EDMONTON TER NE
LEESBURG VA
20176-1829
US

IV. Provider business mailing address

574 EDMONTON TER NE
LEESBURG VA
20176-1829
US

V. Phone/Fax

Practice location:
  • Phone: 443-540-0120
  • Fax:
Mailing address:
  • Phone: 443-540-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number133000306
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number133000306
License Number StateVA

VIII. Authorized Official

Name: KATHERINE WILCOX
Title or Position: FOUNDER
Credential: BCBA
Phone: 443-540-0120