Healthcare Provider Details

I. General information

NPI: 1225260466
Provider Name (Legal Business Name): NORTHEAST AUTISM CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MULBERRY ST
SCRANTON PA
18510-2224
US

IV. Provider business mailing address

1401 MULBERRY ST
SCRANTON PA
18510-2224
US

V. Phone/Fax

Practice location:
  • Phone: 570-558-3198
  • Fax:
Mailing address:
  • Phone: 570-558-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. NATHANIEL L BUSHWICK
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 570-575-2378