Basic Information
| Provider Information | |||||||||
| NPI: | 1124787866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION AUTISM CLINICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 BANKS AVE | ||||||||
| Address2: | |||||||||
| City: | MCADOO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182372508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8872647748 | ||||||||
| FaxNumber: | 5703625112 | ||||||||
| Practice Location | |||||||||
| Address1: | 5310 SPECTRUM DR | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217037362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887264774 | ||||||||
| FaxNumber: | 5703625112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2021 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | DEANGELO | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8887264774 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSION AUTISM CLINICS LLC | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.