Healthcare Provider Details

I. General information

NPI: 1740857952
Provider Name (Legal Business Name): ADVANCED AUTISM SERVICES MI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RENAISSANCE CTR STE 2600
DETROIT MI
48243-1502
US

IV. Provider business mailing address

211 BOULEVARD OF AMERICAS STE 402
LAKEWOOD NJ
08701-4778
US

V. Phone/Fax

Practice location:
  • Phone: 602-584-9860
  • Fax: 602-715-1135
Mailing address:
  • Phone: 602-584-9860
  • Fax: 602-715-1135

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