Provider Demographics
NPI:1891356465
Name:PRINCE, LACHELLE M
Entity Type:Individual
Prefix:
First Name:LACHELLE
Middle Name:M
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BRUCE CT
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5442
Mailing Address - Country:US
Mailing Address - Phone:254-640-5438
Mailing Address - Fax:
Practice Address - Street 1:704 BRUCE CT
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5442
Practice Address - Country:US
Practice Address - Phone:254-640-5438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-19-86145106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-19-86145OtherBEHAVIOR ANALYTIC CERTIFICATION BOARD