Healthcare Provider Details

I. General information

NPI: 1144975889
Provider Name (Legal Business Name): PURPLE HEART AUTISM THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5404 CATALPHA RD
BALTIMORE MD
21214-1925
US

IV. Provider business mailing address

5404 CATALPHA RD
BALTIMORE MD
21214-1925
US

V. Phone/Fax

Practice location:
  • Phone: 443-744-5368
  • Fax:
Mailing address:
  • Phone: 443-744-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: IRISHA LUCAS
Title or Position: OWNER
Credential:
Phone: 443-744-5368