Provider Demographics
NPI:1407264088
Name:HARRIS, MISTYANN HAZEL K (MA ED, BCBA)
Entity Type:Individual
Prefix:
First Name:MISTYANN
Middle Name:HAZEL K
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MA ED, BCBA
Other - Prefix:
Other - First Name:MISTYANN
Other - Middle Name:HAZEL
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2770 GREEN ASH LOOP
Mailing Address - Street 2:APT 301
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4153
Mailing Address - Country:US
Mailing Address - Phone:703-622-0762
Mailing Address - Fax:
Practice Address - Street 1:2770 GREEN ASH LOOP
Practice Address - Street 2:APT 301
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4153
Practice Address - Country:US
Practice Address - Phone:703-622-0762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000444103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst