Healthcare Provider Details

I. General information

NPI: 1750664561
Provider Name (Legal Business Name): FORT WAYNE AUTISM CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 E DUPONT RD
FORT WAYNE IN
46825-1668
US

IV. Provider business mailing address

172 W CARMEL DR
CARMEL IN
46032-2526
US

V. Phone/Fax

Practice location:
  • Phone: 260-245-1455
  • Fax:
Mailing address:
  • Phone: 317-815-5501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY BIERMAN
Title or Position: PRESIDENT
Credential:
Phone: 260-245-1455