=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902570443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE COMMUNITY ABA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2021
-----------------------------------------------------
Last Update Date | 01/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 KASSY LN
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22556-6577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-722-9152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5614 JOSHUA TREE CIR
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22407-9341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. BRIDGET L NKEMATABONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-722-9152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------