Healthcare Provider Details

I. General information

NPI: 1053640490
Provider Name (Legal Business Name): AUTISM CONSULTING NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 EAST 10TH STREET
SANFORD FL
32771
US

IV. Provider business mailing address

203 EAST 10TH STREET
SANFORD FL
32771
US

V. Phone/Fax

Practice location:
  • Phone: 850-583-1911
  • Fax:
Mailing address:
  • Phone: 850-583-1911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberBCBA 1-05-2521
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBCBA 1-05-2521
License Number State

VIII. Authorized Official

Name: MRS. CHRYSTIN BULLOCK
Title or Position: EXECUTIVE DIRECTOR
Credential: MS BCBA
Phone: 850-583-1911