MEDICARE: ETHAN KATZ M.ED, BCBA, LBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-18-30640

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-18-30640	OTHER		BEHAVIOR ANALYST CERTIFICATION BOARD
2	0133001179	OTHER	VA	VIRGINIA DEPARTMENT OF HEALTH PROFESSIONALS

General Provider Information

NPI Number	:	1083193890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN KATZ M.ED, BCBA, LBA

Provider Business Mailing Address
First Line	:	3819 PRINCE WILLIAM DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-3820
Country	:	US
Telephone Number	:	703-346-3185
Fax Number	:

Provider Business Practice Location Address
First Line	:	6563 EDSALL RD
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22151-4414
Country	:	US
Telephone Number	:	703-354-0000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	08/13/2018

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