Healthcare Provider Details

I. General information

NPI: 1538790720
Provider Name (Legal Business Name): MISSION AUTISM CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11921 BOURNEFIELD WAY STE A
SILVER SPRING MD
20904-7815
US

IV. Provider business mailing address

9 BANKS AVE
MCADOO PA
18237-2508
US

V. Phone/Fax

Practice location:
  • Phone: 888-726-4774
  • Fax: 570-362-5112
Mailing address:
  • Phone: 570-459-2889
  • 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 Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAUL BRANDON DEANGELO
Title or Position: CEO
Credential:
Phone: 570-401-6409