Provider Demographics
NPI:1508570482
Name:MARTIN, EMILY ANN (MAT, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MAT, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019B EDWARDS FERRY RD NE # 1085
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3347
Mailing Address - Country:US
Mailing Address - Phone:571-545-0091
Mailing Address - Fax:
Practice Address - Street 1:107 E MAIN ST UNIT C
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-5832
Practice Address - Country:US
Practice Address - Phone:571-545-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001183103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0133001183Medicaid