Healthcare Provider Details

I. General information

NPI: 1144855602
Provider Name (Legal Business Name): LATESHA SHINESE COULTER BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7510 GAMBRILL RD
SPRINGFIELD VA
22153-1809
US

IV. Provider business mailing address

1390 CHAIN BRIDGE RD STE 50097
MC LEAN VA
22101-3904
US

V. Phone/Fax

Practice location:
  • Phone: 509-842-6958
  • Fax:
Mailing address:
  • Phone: 509-842-6958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: