Healthcare Provider Details

I. General information

NPI: 1174298319
Provider Name (Legal Business Name): SANDIA AUTISM SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9123 PALOMAS AVE NE
ALBUQUERQUE NM
87109-6632
US

IV. Provider business mailing address

9123 PALOMAS AVE NE
ALBUQUERQUE NM
87109-6632
US

V. Phone/Fax

Practice location:
  • Phone: 505-274-9018
  • Fax:
Mailing address:
  • Phone: 505-933-5961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: KYLE I WORTMAN
Title or Position: OWNER
Credential: BCBA
Phone: 505-933-5961