Basic Information
| Provider Information | |||||||||
| NPI: | 1104081116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH DAKOTA AUTISM CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 647 13TH AVE E | ||||||||
| Address2: | STE A | ||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580783328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012778844 | ||||||||
| FaxNumber: | 7012778847 | ||||||||
| Practice Location | |||||||||
| Address1: | 647 13TH AVE E | ||||||||
| Address2: | STE A | ||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580783328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012778844 | ||||||||
| FaxNumber: | 7012778847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2008 | ||||||||
| LastUpdateDate: | 09/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7012778844 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.