Healthcare Provider Details

I. General information

NPI: 1689257354
Provider Name (Legal Business Name): OLD TOWN ABA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NEVERMORE DRIVE
WINCHESTER VA
22602
US

IV. Provider business mailing address

111 NEVERMORE DRIVE
WINCHESTER VA
22602
US

V. Phone/Fax

Practice location:
  • Phone: 703-727-9417
  • Fax:
Mailing address:
  • Phone: 703-727-9417
  • 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 Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. RACHEL NICOLE EVANS
Title or Position: OWNER
Credential: BCBA
Phone: 703-727-9417