Provider Demographics
NPI:1013388529
Name:GROVE, LAURE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:LAURE
Middle Name:
Last Name:GROVE
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6281 FRANCONIA RD STE B
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2587
Mailing Address - Country:US
Mailing Address - Phone:571-249-4883
Mailing Address - Fax:
Practice Address - Street 1:6281 FRANCONIA RD STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2587
Practice Address - Country:US
Practice Address - Phone:571-249-4883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-15-19647103K00000X
VA0133001029103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0133001029OtherVA BA LICENSE