Provider Demographics
NPI:1457015935
Name:EVANS, MADISON MARIE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 LYNNHAVEN PKWY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7332
Mailing Address - Country:US
Mailing Address - Phone:804-207-3878
Mailing Address - Fax:
Practice Address - Street 1:400 HERNDON PKWY STE 150
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5204
Practice Address - Country:US
Practice Address - Phone:804-207-3878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA1-24-70910103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician