Basic Information
Provider Information | |||||||||
NPI: | 1538790720 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MISSION AUTISM CLINICS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9 BANKS AVE | ||||||||
Address2: |   | ||||||||
City: | MCADOO | ||||||||
State: | PA | ||||||||
PostalCode: | 182372508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5704592889 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11921 BOURNEFIELD WAY STE A | ||||||||
Address2: |   | ||||||||
City: | SILVER SPRING | ||||||||
State: | MD | ||||||||
PostalCode: | 209047815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8887264774 | ||||||||
FaxNumber: | 5703625112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2020 | ||||||||
LastUpdateDate: | 12/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEANGELO | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | BRANDON | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5704016409 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 103K00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.