Healthcare Provider Details

I. General information

NPI: 1730179995
Provider Name (Legal Business Name): ROCHESTER CENTER FOR AUTISM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 4TH AVE SW
ROCHESTER MN
55902-3834
US

IV. Provider business mailing address

1220 4TH AVE SW
ROCHESTER MN
55902-3834
US

V. Phone/Fax

Practice location:
  • Phone: 507-424-3234
  • Fax: 507-424-3235
Mailing address:
  • Phone: 507-424-3234
  • Fax: 507-424-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP0911
License Number StateMN

VIII. Authorized Official

Name: MRS. MANDY MARIE EGGERT
Title or Position: DIRECTOR/PROGRAM SUPERVISOR
Credential:
Phone: 507-424-3234