Basic Information
| Provider Information | |||||||||
| NPI: | 1720212749 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KYO AUTISM THERAPY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GATEWAY LEARNING GROUP, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 295 89TH ST STE 306 | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940151656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772646747 | ||||||||
| FaxNumber: | 8775397730 | ||||||||
| Practice Location | |||||||||
| Address1: | 295 89TH ST STE 306 | ||||||||
| Address2: | |||||||||
| City: | DALY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940151656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772646747 | ||||||||
| FaxNumber: | 8775397730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2009 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVITIAN | ||||||||
| AuthorizedOfficialFirstName: | COLIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8772646747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1042076 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.