Provider Demographics
NPI:1902302268
Name:ROUSHANMEIDAN, MANDANA (BCBA)
Entity Type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:ROUSHANMEIDAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6862 ELM ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3857
Mailing Address - Country:US
Mailing Address - Phone:703-821-1073
Mailing Address - Fax:
Practice Address - Street 1:6862 ELM ST STE 205
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3857
Practice Address - Country:US
Practice Address - Phone:703-821-1073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-8-30161103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst