Provider Demographics
NPI:1235522442
Name:DEITZ, BETHANY (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:DEITZ
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 1:110 NIGHTBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-2960
Mailing Address - Country:US
Mailing Address - Phone:540-771-7254
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102
Practice Address - Country:US
Practice Address - Phone:800-828-5659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
VA0133000596103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251S00000XAgenciesCommunity/Behavioral Health