Provider Demographics
NPI:1619669801
Name:MILES, PAYTON GRISSOM (BCBA)
Entity type:Individual
Prefix:MRS
First Name:PAYTON
Middle Name:GRISSOM
Last Name:MILES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MISS
Other - First Name:PAYTON
Other - Middle Name:REBECCA
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:4910 CYPRESS POINT CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6872
Mailing Address - Country:US
Mailing Address - Phone:757-633-0912
Mailing Address - Fax:
Practice Address - Street 1:989 KELSO CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3054
Practice Address - Country:US
Practice Address - Phone:757-642-4705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA0133003961103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician