Basic Information
Provider Information | |||||||||
NPI: | 1477219236 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AUTISM THERAPEUTIC SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2919 BREEZEWOOD AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283035283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11815 FOUNTAIN WAY STE 300 | ||||||||
Address2: |   | ||||||||
City: | NEWPORT NEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 236064448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9104841711 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2021 | ||||||||
LastUpdateDate: | 11/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCOTT | ||||||||
AuthorizedOfficialFirstName: | TERRA | ||||||||
AuthorizedOfficialMiddleName: | RAE | ||||||||
AuthorizedOfficialTitleorPosition: | SVP OUTPATIENT PEDIATRICS | ||||||||
AuthorizedOfficialTelephone: | 3034374364 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: | 11/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.