Provider Demographics
NPI:1063713808
Name:DIVELBISS, KATIE (MS, BCBA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:DIVELBISS
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 SHAWNEE RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-2300
Mailing Address - Country:US
Mailing Address - Phone:703-750-0633
Mailing Address - Fax:703-750-0655
Practice Address - Street 1:5400 SHAWNEE RD
Practice Address - Street 2:SUITE 208
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-2300
Practice Address - Country:US
Practice Address - Phone:703-750-0633
Practice Address - Fax:703-750-0655
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-10-7769103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst