Provider Demographics
NPI:1720597834
Name:PRUE, KATELYN E (BCBA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:E
Last Name:PRUE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3629
Mailing Address - Country:US
Mailing Address - Phone:716-531-5564
Mailing Address - Fax:
Practice Address - Street 1:5414 BACKLICK ROAD
Practice Address - Street 2:C
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151
Practice Address - Country:US
Practice Address - Phone:716-531-5564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-17-27061103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst