Healthcare Provider Details

I. General information

NPI: 1750979233
Provider Name (Legal Business Name): WOLFF & PHAN AUTISM CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 EMBASSY PKWY STE 100
FAIRLAWN OH
44333-8403
US

IV. Provider business mailing address

3505 EMBASSY PKWY STE 100
FAIRLAWN OH
44333-8403
US

V. Phone/Fax

Practice location:
  • Phone: 330-271-6107
  • Fax: 330-706-4705
Mailing address:
  • Phone: 330-271-6107
  • Fax: 330-706-4705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KIM PHAN WOLFF
Title or Position: CEO & FOUNDER
Credential: BCBA, COBA
Phone: 330-271-6107