Healthcare Provider Details

I. General information

NPI: 1871615393
Provider Name (Legal Business Name): NORTH GEORGIA AUTISM CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 DAHLONEGA HWY
CUMMING GA
30040-4528
US

IV. Provider business mailing address

PO BOX 38
CUMMING GA
30028-0038
US

V. Phone/Fax

Practice location:
  • Phone: 770-844-8624
  • Fax: 770-844-8643
Mailing address:
  • Phone: 770-844-8624
  • Fax: 770-844-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC001104
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR007818
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSICA LYNN PUGH
Title or Position: PRESIDENT
Credential: M.S., BCBA
Phone: 770-844-8624