Provider Demographics
NPI:1710515531
Name:EAGEN, MADISON (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:EAGEN
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 1:11576 GREENWICH POINT RD
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-1200
Mailing Address - Country:US
Mailing Address - Phone:703-303-3902
Mailing Address - Fax:
Practice Address - Street 1:11576 GREENWICH POINT RD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20194-1200
Practice Address - Country:US
Practice Address - Phone:703-303-3902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001686103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst