MEDICARE: AVERY ALLEN 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	1-18-32167

General Provider Information

NPI Number	:	1275947947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVERY ALLEN BCBA, LBA

Provider Business Mailing Address
First Line	:	6400 GROVEDALE DR STE 200
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22310-2504
Country	:	US
Telephone Number	:	603-801-0575
Fax Number	:

Provider Business Practice Location Address
First Line	:	6400 GROVEDALE DR STE 200
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22310-2504
Country	:	US
Telephone Number	:	603-801-0575
Fax Number	:

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

Provider Enumeration Date	:	06/20/2014
Last Update Date	:	11/04/2024

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