Healthcare Provider Details

I. General information

NPI: 1104584697
Provider Name (Legal Business Name): ECHOIC AUTISM CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 JEFFERSON STREET EXT # C327
NEWNAN GA
30263-1627
US

IV. Provider business mailing address

414 JEFFERSON STREET EXT # C327
NEWNAN GA
30263-1627
US

V. Phone/Fax

Practice location:
  • Phone: 470-883-2733
  • Fax:
Mailing address:
  • Phone: 470-883-2733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAREE ROSS
Title or Position: OWNER
Credential:
Phone: 470-883-2733