Provider Demographics
NPI:1942798251
Name:YOUNG, DIANE ELIZABETH (BCABA, LABA)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:YOUNG
Suffix:
Gender:F
Credentials:BCABA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 RANDOM HILLS RD STE 240
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6044
Mailing Address - Country:US
Mailing Address - Phone:703-537-0700
Mailing Address - Fax:
Practice Address - Street 1:11350 RANDOM HILLS RD STE 240
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6044
Practice Address - Country:US
Practice Address - Phone:703-537-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000201103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst