Provider Demographics
NPI:1063765154
Name:BLACK, JANET ELIZABETH (MED, BCBA)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 SCOTLAND RD
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17202-9779
Mailing Address - Country:US
Mailing Address - Phone:717-263-8953
Mailing Address - Fax:717-263-0086
Practice Address - Street 1:3020 HAMAKER CT
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2238
Practice Address - Country:US
Practice Address - Phone:703-573-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1073226103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst