Provider Demographics
NPI:1558936278
Name:AVEDICIAN, LISA L (RBT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:AVEDICIAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 INDIAN WOOD LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-1834
Mailing Address - Country:US
Mailing Address - Phone:717-994-8435
Mailing Address - Fax:
Practice Address - Street 1:1641 BELCHER MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MEADOWS OF DAN
Practice Address - State:VA
Practice Address - Zip Code:24120-3672
Practice Address - Country:US
Practice Address - Phone:540-840-9285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-15-04936106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician