Provider Demographics
NPI:1972928356
Name:WILSON, DEANA BROOKE (MED, BCBA)
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:BROOKE
Last Name:WILSON
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:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20172-0748
Mailing Address - Country:US
Mailing Address - Phone:571-524-0209
Mailing Address - Fax:703-890-7252
Practice Address - Street 1:779 STATION ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4607
Practice Address - Country:US
Practice Address - Phone:571-524-0209
Practice Address - Fax:703-890-7252
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000012103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst