Provider Demographics
NPI:1700121134
Name:VICKSTROM, JOSHUA KENT (BCABA)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:KENT
Last Name:VICKSTROM
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 DIXIE HILL RD
Mailing Address - Street 2:APARTMENT 309
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-9086
Mailing Address - Country:US
Mailing Address - Phone:804-994-4461
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD
Practice Address - Street 2:SUITE NUMBER 600
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4311
Practice Address - Country:US
Practice Address - Phone:800-828-5659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0-12-5227103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst