MEDICARE: MR. MARK WILLER 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	1-12-11579	VA

General Provider Information

NPI Number	:	1609123835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK WILLER BCBA

Provider Business Mailing Address
First Line	:	4102 MIDDLE RIDGE DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033
Country	:	US
Telephone Number	:	703-507-9992
Fax Number	:

Provider Business Practice Location Address
First Line	:	4102 MIDDLE RIDGE DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-3226
Country	:	US
Telephone Number	:	703-507-9992
Fax Number	:

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

Provider Enumeration Date	:	08/07/2012
Last Update Date	:	08/07/2012

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Directions to “ MR. MARK WILLER BCBA” Practice Location

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