Provider Demographics
NPI:1215325972
Name:ANGLIN, PHAEDRA (BCBA)
Entity type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:
Last Name:ANGLIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:PHAEDRA
Other - Middle Name:
Other - Last Name:SARGENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4445 CORPORATION LN
Mailing Address - Street 2:SUITE 264
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4445 CORPORATION LN
Practice Address - Street 2:SUITE 264
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3262
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-14-17799103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst