Healthcare Provider Details

I. General information

NPI: 1639004922
Provider Name (Legal Business Name): TOMMY HARRISON III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11511 SUNSET HILLS RD
RESTON VA
20190-4704
US

IV. Provider business mailing address

9706 KEYSER RD
NOKESVILLE VA
20181-3312
US

V. Phone/Fax

Practice location:
  • Phone: 603-732-3415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: