Basic Information
Provider Information | |||||||||
NPI: | 1790209526 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STAFFORD EARLY AUTISM SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 538 APRICOT STREET | ||||||||
Address2: |   | ||||||||
City: | STAFFORD | ||||||||
State: | VA | ||||||||
PostalCode: | 22554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5406234127 | ||||||||
FaxNumber: | 5403012778 | ||||||||
Practice Location | |||||||||
Address1: | 538 APRICOT STREET | ||||||||
Address2: |   | ||||||||
City: | STAFFORD | ||||||||
State: | VA | ||||||||
PostalCode: | 22554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5406234127 | ||||||||
FaxNumber: | 5403012778 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDMONDS | ||||||||
AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BEHAVIOR ANALYST | ||||||||
AuthorizedOfficialTelephone: | 5406234127 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BCBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0133000789 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.