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General NPI Number Information
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NPI Number | 1295059418
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Entity Type | Organization
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Legal Business Name | BEHAVIORAL THERAPY AND CONSULTATION VA LLC
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Dates
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Enumeration Date | 03/17/2010
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Last Update Date | 03/17/2010
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Provider Practice Location Address
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Address Line | 3073 ANTRIM CIR
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City | DUMFRIES
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State | VA
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Zip | 22026-3319
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Country | US
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Telephone | 571-251-1859
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Fax | 703-441-7814
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Provider Business Mailing Address
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Address Line | 12359 SUNRISE VALLEY DR 220
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City | RESTON
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State | VA
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Zip | 20191-3462
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Country | US
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Telephone | 571-251-1859
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Fax | 703-441-7814
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Authorized Official
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Title or Position | BEHAVIOR ANALYST
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Name | KELLY L EAKIN
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Credential | BCBA
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Telephone | 571-251-1859
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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 | 1-09-6402
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License Number State | VA
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