Healthcare Provider Details

I. General information

NPI: 1912570797
Provider Name (Legal Business Name): CLUBHOUSE AUTISM AND DEVELOPMENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 COLLEGE AVE
JACKSON AL
36545-2402
US

IV. Provider business mailing address

PO BOX 759
CHATOM AL
36518-0759
US

V. Phone/Fax

Practice location:
  • Phone: 251-769-0021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SAVANNA WILLIAMS
Title or Position: OWNER
Credential: SLP
Phone: 251-751-1687