=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598411126
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT CROSS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2022
-----------------------------------------------------
Last Update Date | 02/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20566 TIMBERLAKE RD STE A
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502-7221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-239-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 231 COLONNADE DR APT 5
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22903-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-239-8596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-22-200304
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------