Healthcare Provider Details

I. General information

NPI: 1922378991
Provider Name (Legal Business Name): THE ILLINOIS CENTER FOR AUTISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 S RUBY LN
FAIRVIEW HEIGHTS IL
62208-2614
US

IV. Provider business mailing address

548 S RUBY LN
FAIRVIEW HEIGHTS IL
62208-2614
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-7500
  • Fax: 618-394-9869
Mailing address:
  • Phone: 618-398-7500
  • Fax: 618-394-9869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUSAN SZEKELY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-398-7500