Basic Information
| Provider Information | |||||||||
| NPI: | 1699294314 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA AUTISM CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 INTERNATIONAL PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4708166449 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4085 HANCOCK BRIDGE PKWY STE 101 | ||||||||
| Address2: | |||||||||
| City: | NORTH FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | 4075886294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2017 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | OWEN | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4708166449 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA AUTISM CENTER | ||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | 106S00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | 103K00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.