Healthcare Provider Details

I. General information

NPI: 1366773012
Provider Name (Legal Business Name): GOALS FOR AUTISM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S BROADWAY STE 310
WALNUT CREEK CA
94596-5218
US

IV. Provider business mailing address

800 S BROADWAY STE 310
WALNUT CREEK CA
94596-5218
US

V. Phone/Fax

Practice location:
  • Phone: 415-915-9408
  • Fax:
Mailing address:
  • Phone: 888-531-8385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ADRYON KETCHAM
Title or Position: CEO
Credential:
Phone: 415-915-9408