Healthcare Provider Details

I. General information

NPI: 1902687981
Provider Name (Legal Business Name): CREEKSIDE AUTISM CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 JOHNS CREEK PKWY STE B
SUWANEE GA
30024-1213
US

IV. Provider business mailing address

4055 JOHNS CREEK PKWY STE A
SUWANEE GA
30024-1299
US

V. Phone/Fax

Practice location:
  • Phone: 770-888-5221
  • Fax: 678-680-5929
Mailing address:
  • Phone: 770-888-5221
  • Fax: 678-680-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MYRLAINE DARIUS
Title or Position: ADMIN DIRECTOR
Credential:
Phone: 770-888-5221