Healthcare Provider Details

I. General information

NPI: 1760316319
Provider Name (Legal Business Name): SHADMAN ISLAM RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CARRIEBROOKE DR
STEPHENS CITY VA
22655-6000
US

IV. Provider business mailing address

131 ELDEN ST STE 302
HERNDON VA
20170-4851
US

V. Phone/Fax

Practice location:
  • Phone: 540-486-4653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-255708
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: