Provider Demographics
NPI:1316455181
Name:EATON, ANGELINE VIRGINIA (BCBA, M ED)
Entity type:Individual
Prefix:
First Name:ANGELINE
Middle Name:VIRGINIA
Last Name:EATON
Suffix:
Gender:F
Credentials:BCBA, M ED
Other - Prefix:
Other - First Name:ANGELINE
Other - Middle Name:VIRGINIA
Other - Last Name:GEHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA, MED
Mailing Address - Street 1:472 CAPAC RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48002-4202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD STE 600
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4389
Practice Address - Country:US
Practice Address - Phone:703-506-0123
Practice Address - Fax:886-857-0246
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-28494103K00000X
CO01-17-28494103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst