Provider Demographics
NPI:1659820009
Name:PHELPS, BRIAN (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PHELPS
Suffix:
Gender:M
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13708 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-5603
Mailing Address - Country:US
Mailing Address - Phone:804-895-2572
Mailing Address - Fax:
Practice Address - Street 1:11311 BUSINESS CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3199
Practice Address - Country:US
Practice Address - Phone:804-378-6141
Practice Address - Fax:804-378-6183
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000812103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst