Healthcare Provider Details

I. General information

NPI: 1528675329
Provider Name (Legal Business Name): NORTHWEST AUTISM DIAGNOSTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

394 FEDERAL DR
CRYSTAL LAKE IL
60014-6281
US

IV. Provider business mailing address

PO BOX 2257
CHESTERTON IN
46304-0357
US

V. Phone/Fax

Practice location:
  • Phone: 224-206-5415
  • Fax:
Mailing address:
  • Phone: 219-926-8320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: COURTNEY DIRKSEN
Title or Position: OWNER
Credential: PHD
Phone: 224-206-5415