Provider Demographics
NPI:1225894066
Name:PEARSON, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 FORBES ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-2017
Mailing Address - Country:US
Mailing Address - Phone:540-710-3911
Mailing Address - Fax:
Practice Address - Street 1:9833 PATRIOT HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-9422
Practice Address - Country:US
Practice Address - Phone:540-710-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA21-164927106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician