Healthcare Provider Details

I. General information

NPI: 1497471478
Provider Name (Legal Business Name): BLUE AUTISM SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PECAN TREE LN
FORT MILL SC
29715-7010
US

IV. Provider business mailing address

836 PECAN TREE LN
FORT MILL SC
29715-7010
US

V. Phone/Fax

Practice location:
  • Phone: 609-439-1032
  • Fax:
Mailing address:
  • Phone: 609-439-1032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. VIVEK R SAMA
Title or Position: OWNER FOUNDER
Credential:
Phone: 609-439-1032