=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467985721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABA BEHAVIORAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2017
-----------------------------------------------------
Last Update Date | 10/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 RIDING TRAIL LN
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22727-4160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-614-8023
-----------------------------------------------------
Fax | 540-300-2841
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 RIDING TRAIL LN
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22727-4160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-614-8023
-----------------------------------------------------
Fax | 540-300-2841
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PROVIDER
-----------------------------------------------------
Name | MICHELLE WINDSOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 334-614-8023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------