Provider Demographics
NPI:1710398730
Name:SUMMIT BEHAVIOR THERAPY, LLC
Entity Type:Organization
Organization Name:SUMMIT BEHAVIOR THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA, LBA
Authorized Official - Phone:757-962-9110
Mailing Address - Street 1:1030 JAMESTOWN CRES
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-1260
Mailing Address - Country:US
Mailing Address - Phone:757-962-9110
Mailing Address - Fax:
Practice Address - Street 1:1030 JAMESTOWN CRES
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-1260
Practice Address - Country:US
Practice Address - Phone:757-962-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000397103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty