MEDICARE: MR. JOHN PRUETT BCBA

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
2	103K00000X	Behavior Analyst	3108	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184283525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN PRUETT BCBA

Provider Business Mailing Address
First Line	:	7420 FULLERTON RD STE 104
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22153-2836
Country	:	US
Telephone Number	:	703-463-7174
Fax Number	:	781-437-1200

Provider Business Practice Location Address
First Line	:	7420 FULLERTON RD STE 104
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22153-2836
Country	:	US
Telephone Number	:	703-463-7174
Fax Number	:	781-437-1200

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

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	03/25/2024

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