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General NPI Number Information
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NPI Number | 1134594864
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Entity Type | Organization
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Legal Business Name | DOMINION ABA
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Dates
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Enumeration Date | 12/07/2015
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Last Update Date | 12/07/2015
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Provider Practice Location Address
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Address Line | 2903 BOULEAVARD
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City | COLONIAL HEIGHTS
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State | VA
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Zip | 23834
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Country | US
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Telephone | 804-484-4719
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Fax |
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Provider Business Mailing Address
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Address Line | 2903 BOULEVARD
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City | COLONIAL HEIGHTS
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State | VA
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Zip | 23834-2401
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Country | US
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Telephone | 804-484-4719
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Fax |
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Authorized Official
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Title or Position | ASSISTANT BEHAVIOR ANALYST
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Name | MR. MATTHEW DOUGLAS WYNN
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Credential | LABA
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Telephone | 804-484-4719
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 0-15-6783
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License Number State | VA
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