MEDICARE: FAMILYPATH AUTISM SERVICES, LLC

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	103T00000X	Psychologist	222957	WI
2	106H00000X	Marriage & Family Therapist	674124	WI

General Provider Information

NPI Number	:	1457756595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILYPATH AUTISM SERVICES, LLC

Provider Business Mailing Address
First Line	:	2310 CROSSROADS DR.
Second Line	:	SUITE 4500
City	:	MADISON
State	:	WI
Zip	:	53718-7607
Country	:	US
Telephone Number	:	608-512-0780
Fax Number	:	608-841-1059

Provider Business Practice Location Address
First Line	:	2310 CROSSROADS DR.
Second Line	:	SUITE 4500
City	:	MADISON
State	:	WI
Zip	:	53718-7607
Country	:	US
Telephone Number	:	608-512-0780
Fax Number	:	608-841-1059

Authorized Official
Title or Position	:	FINANCE DIRECTOR/CO-OWNER
Name	:	CONNIE THOMAS
Credential	:
Telephone Number	:	608-512-0783

Provider Enumeration Date	:	10/31/2014
Last Update Date	:	05/18/2026

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