Provider Demographics
NPI:1134727985
Name:PAGE, PHILIP
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 CARLISLE DR STE B
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5614
Mailing Address - Country:US
Mailing Address - Phone:254-640-6438
Mailing Address - Fax:571-336-5314
Practice Address - Street 1:435 CARLISLE DR STE B
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5614
Practice Address - Country:US
Practice Address - Phone:254-640-6438
Practice Address - Fax:571-336-5314
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-20-136550106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VARBT-20-136550OtherBEHAVIOR ANALYTIC CERTIFICATION BOARD