Provider Demographics
NPI:1073244687
Name:WANG, JIA (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JIA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12504 TRIADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-1152
Mailing Address - Country:US
Mailing Address - Phone:240-319-1309
Mailing Address - Fax:
Practice Address - Street 1:12504 TRIADELPHIA RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-1152
Practice Address - Country:US
Practice Address - Phone:240-319-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-21-51256103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty