Basic Information
| Provider Information | |||||||||
| NPI: | 1568128320 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUTISM THERAPEUTIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2919 BREEZEWOOD AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283035283 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11815 FOUNTAIN WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236064448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104841711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2021 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | TERRA | ||||||||
| AuthorizedOfficialMiddleName: | RAE | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP OUTPATIENT PEDIATRICS | ||||||||
| AuthorizedOfficialTelephone: | 3034374364 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | N | 193200000X MULTI-SPECIALTY GROUP | 106S00000X | N | 193200000X MULTI-SPECIALTY GROUP | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.