Healthcare Provider Details

I. General information

NPI: 1245578475
Provider Name (Legal Business Name): PETALU'DA AUTISM SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 11/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 ELIZABETH LN
VERNON CT
06066-5056
US

IV. Provider business mailing address

6 ELIZABETH LN
VERNON CT
06066-5056
US

V. Phone/Fax

Practice location:
  • Phone: 860-983-8112
  • Fax:
Mailing address:
  • Phone: 860-983-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11211741
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number3928518916
License Number StateCT

VIII. Authorized Official

Name: MISS KEISHA POWELL
Title or Position: AUTISM THERAPIST
Credential: SPED/CASD
Phone: 860-983-8112