Healthcare Provider Details

I. General information

NPI: 1790729069
Provider Name (Legal Business Name): AUTISM LEARNING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N. 29TH ST
MONROE LA
71201
US

IV. Provider business mailing address

810 N. 29TH ST.
MONROE LA
71201
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-1223
  • Fax: 318-323-1224
Mailing address:
  • Phone: 318-323-1223
  • Fax: 318-323-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1059396
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5508
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-08-4659
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANICE MOSS
Title or Position: INSURANCE ADMINISTRATOR
Credential:
Phone: 318-323-1223