Provider Demographics
NPI:1134594864
Name:DOMINION ABA
Entity type:Organization
Organization Name:DOMINION ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT BEHAVIOR ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:LABA
Authorized Official - Phone:804-484-4719
Mailing Address - Street 1:2903 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2401
Mailing Address - Country:US
Mailing Address - Phone:804-484-4719
Mailing Address - Fax:
Practice Address - Street 1:2903 BOULEAVARD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834
Practice Address - Country:US
Practice Address - Phone:804-484-4719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0-15-6783252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency