MEDICARE: AUTISM DIAGNOSTIC SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103TC2200X	Clinical Child & Adolescent Psychologist
2	235Z00000X	Speech-Language Pathologist
3	2080P0008X	Pediatric Neurodevelopmental Disabilities Physician

General Provider Information

NPI Number	:	1326721028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTISM DIAGNOSTIC SERVICES LLC

Provider Business Mailing Address
First Line	:	30 N GOULD ST STE R
Second Line	:
City	:	SHERIDAN
State	:	WY
Zip	:	82801-6317
Country	:	US
Telephone Number	:	702-213-2123
Fax Number	:

Provider Business Practice Location Address
First Line	:	1775 VILLAGE CENTER CIR STE 190
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-0571
Country	:	US
Telephone Number	:	702-213-2123
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST/ CEO
Name	:	MS. KATHERINE WALLISCH
Credential	:	M.S.,CCC-SLP
Telephone Number	:	702-213-2123

Provider Enumeration Date	:	08/09/2023
Last Update Date	:	08/09/2023

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Directions to “AUTISM DIAGNOSTIC SERVICES LLC ” Practice Location

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