Healthcare Provider Details

I. General information

NPI: 1427705094
Provider Name (Legal Business Name): LICENSED BEHAVIOR ANALYSIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 BROWNSHIRE TRAIL
VIRGINIA BEACH VA
23456
US

IV. Provider business mailing address

2280 BROWNSHIRE TRL
VIRGINIA BEACH VA
23456-5286
US

V. Phone/Fax

Practice location:
  • Phone: 757-447-0883
  • Fax:
Mailing address:
  • Phone: 757-777-5560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHRIS A. JORDAN
Title or Position: PRESIDENT
Credential: BCBA/LBA
Phone: 757-447-0883