Healthcare Provider Details

I. General information

NPI: 1700189222
Provider Name (Legal Business Name): AUTISM INTERVENTION SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 GROVE STREET
WORCESTER MA
01605
US

IV. Provider business mailing address

324 GROVE STREET
WORCESTER MA
01605
US

V. Phone/Fax

Practice location:
  • Phone: 855-295-3276
  • Fax: 818-241-6853
Mailing address:
  • Phone: 855-646-8247
  • Fax: 818-241-6853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-08-4817
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9482
License Number StateMA

VIII. Authorized Official

Name: MR. JEFFREY WINTER
Title or Position: C.E.O.
Credential:
Phone: 818-241-6780