Healthcare Provider Details

I. General information

NPI: 1538898440
Provider Name (Legal Business Name): ADVANCED AUTISM SERVICES IN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 RIVER CROSSING PKWY STE 100
INDIANAPOLIS IN
46240-7766
US

IV. Provider business mailing address

36 AIRPORT RD STE 105
LAKEWOOD NJ
08701-7034
US

V. Phone/Fax

Practice location:
  • Phone: 602-584-9860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MALKA HERSKO
Title or Position: DIRECTOR
Credential: MS CCC SLP
Phone: 602-584-9860