MEDICARE: PRIME AUTISM CENTER INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist

General Provider Information

NPI Number	:	1396311577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME AUTISM CENTER INC

Provider Business Mailing Address
First Line	:	322 W LAKE ST STE 207
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-5202
Country	:	US
Telephone Number	:	612-900-2854
Fax Number	:

Provider Business Practice Location Address
First Line	:	322 W LAKE ST STE 207
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-5202
Country	:	US
Telephone Number	:	612-900-2854
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHAFICI D ALI
Credential	:
Telephone Number	:	612-900-2854

Provider Enumeration Date	:	05/28/2021
Last Update Date	:	05/28/2021

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