Healthcare Provider Details

I. General information

NPI: 1437800604
Provider Name (Legal Business Name): AUTISM LIVING EXPERIENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8604 CLIFF CAMERON DR STE 180
CHARLOTTE NC
28269-8508
US

IV. Provider business mailing address

1990 MAIN ST STE 750
SARASOTA FL
34236-8000
US

V. Phone/Fax

Practice location:
  • Phone: 888-392-8642
  • Fax:
Mailing address:
  • Phone: 888-392-8642
  • Fax: 888-783-7611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TODD STUCKEY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 888-392-8642