Healthcare Provider Details

I. General information

NPI: 1669038584
Provider Name (Legal Business Name): AUTISM HOME SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8533 S PAULINA ST
CHICAGO IL
60620-4747
US

IV. Provider business mailing address

8533 S PAULINA ST
CHICAGO IL
60620-4747
US

V. Phone/Fax

Practice location:
  • Phone: 773-677-8950
  • Fax:
Mailing address:
  • Phone: 773-677-8950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA GONZALEZ
Title or Position: BCBBA
Credential:
Phone: 773-983-0001