=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336816065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT ABA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 08/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 SMARTTS LANE NE
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-309-5295
-----------------------------------------------------
Fax | 703-935-9723
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 SMARTTS LANE NE
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-309-5295
-----------------------------------------------------
Fax | 703-935-9723
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. JANET L ROGERS
-----------------------------------------------------
Credential | MED, BCBA, LBA
-----------------------------------------------------
Telephone | 703-309-5295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------