Provider Demographics
NPI:1659735157
Name:VILLARIN, KIMTRACY (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KIMTRACY
Middle Name:
Last Name:VILLARIN
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 HERNDON PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4469
Mailing Address - Country:US
Mailing Address - Phone:571-762-0500
Mailing Address - Fax:571-241-8557
Practice Address - Street 1:297 HERNDON PKWY STE 301
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4469
Practice Address - Country:US
Practice Address - Phone:571-762-0500
Practice Address - Fax:571-241-8557
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001090103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst