Healthcare Provider Details

I. General information

NPI: 1316342934
Provider Name (Legal Business Name): GREEN BOX ABA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 09/14/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6216 OLD KEENE MILL CT
SPRINGFIELD VA
22152-2323
US

IV. Provider business mailing address

7704 GROMWELL CT
SPRINGFIELD VA
22152-3134
US

V. Phone/Fax

Practice location:
  • Phone: 571-297-4308
  • Fax: 703-992-0405
Mailing address:
  • Phone: 703-975-2791
  • Fax: 703-639-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0133000288
License Number StateVA

VIII. Authorized Official

Name: CHRISTOPHER RICHARDSON
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 571-297-4308