Provider Demographics
NPI:1083193890
Name:KATZ, ETHAN (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:KATZ
Suffix:
Gender:M
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 PRINCE WILLIAM DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3820
Mailing Address - Country:US
Mailing Address - Phone:703-346-3185
Mailing Address - Fax:
Practice Address - Street 1:6563 EDSALL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-4414
Practice Address - Country:US
Practice Address - Phone:703-354-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-30640103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-18-30640OtherBEHAVIOR ANALYST CERTIFICATION BOARD
VA0133001179OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONALS