Provider Demographics
NPI:1699386318
Name:MAYO, JOSEPH IVAN
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:IVAN
Last Name:MAYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 WELLESLEY DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5731
Mailing Address - Country:US
Mailing Address - Phone:571-314-3046
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4311
Practice Address - Country:US
Practice Address - Phone:800-828-5659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician