Healthcare Provider Details

I. General information

NPI: 1265066385
Provider Name (Legal Business Name): AUTISM DIAGNOSTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 INTERNATIONAL MALL
LAS CRUCES NM
88003
US

IV. Provider business mailing address

P.O. BOX 30001 MSC 3SPE
LAS CRUCES NM
88003
US

V. Phone/Fax

Practice location:
  • Phone: 575-646-2235
  • Fax: 575-646-7712
Mailing address:
  • Phone: 575-646-2235
  • Fax: 575-646-7712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DENISE M. SANCHEZ
Title or Position: COLLEGE ASSISTANT PROFESSOR/SLP
Credential: M.A., CCC-SLP
Phone: 575-646-2235