Provider Demographics
NPI:1225485477
Name:EGAN, KATHLEEN (CCC-SLP, BCBA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:EGAN
Suffix:
Gender:F
Credentials:CCC-SLP, BCBA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:EGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCC-SLP, BCBA
Mailing Address - Street 1:11551 IVY BUSH CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-2253
Mailing Address - Country:US
Mailing Address - Phone:571-216-6945
Mailing Address - Fax:
Practice Address - Street 1:11551 IVY BUSH CT
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-2253
Practice Address - Country:US
Practice Address - Phone:571-216-6945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000724103K00000X
VA2202004421235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst