Healthcare Provider Details

I. General information

NPI: 1730843582
Provider Name (Legal Business Name): AUTISM LIVING EXPERIENCE OF CALIFORNIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 COVE CT
SAN MARCOS CA
92069-3528
US

IV. Provider business mailing address

6700 ALEXANDER BELL DR STE 253
COLUMBIA MD
21046-2122
US

V. Phone/Fax

Practice location:
  • Phone: 443-838-9065
  • Fax:
Mailing address:
  • Phone: 443-838-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: TODD STUCKEY
Title or Position: CFO
Credential:
Phone: 443-838-9065