Basic Information
| Provider Information | |||||||||
| NPI: | 1558037507 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPWARD AUTISM CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4505 WATERLEAF CT | ||||||||
| Address2: | |||||||||
| City: | POWDER SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023384266 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4505 WATERLEAF CT | ||||||||
| Address2: | |||||||||
| City: | POWDER SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023384266 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2021 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | RAVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/CENTER DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5023384266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MS, BCBA | ||||||||
| NPICertificationDate: | 07/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-18-32530 | 01 | GA | BCBA CERTIFICATE | OTHER |