Healthcare Provider Details

I. General information

NPI: 1487399390
Provider Name (Legal Business Name): GENESIS AUTISM CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2206 EXECUTIVE DR STE A
HAMPTON VA
23666-2583
US

IV. Provider business mailing address

2202 EXECUTIVE DR STE C
HAMPTON VA
23666-6604
US

V. Phone/Fax

Practice location:
  • Phone: 929-436-3747
  • Fax: 757-838-2573
Mailing address:
  • Phone: 757-827-7707
  • Fax: 757-838-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CAMERON SEVERO ASHWORTH
Title or Position: OWNER
Credential:
Phone: 757-927-1527