=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922760800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL LEIGH BURRIS RBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2021
-----------------------------------------------------
Last Update Date | 10/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3433 BRAMBLETON AVE STE 201A
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-6527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-239-0227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1763 SMITH LN
-----------------------------------------------------
City | PULASKI
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24301-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-239-0227
-----------------------------------------------------
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-21-164390
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------