Healthcare Provider Details

I. General information

NPI: 1033785340
Provider Name (Legal Business Name): ADVANCED AUTISM SERVICES VA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 06/28/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 LYNNHAVEN PKWY STE 400
VIRGINIA BEACH VA
23452-7332
US

IV. Provider business mailing address

36 AIRPORT RD STE 105
LAKEWOOD NJ
08701-7034
US

V. Phone/Fax

Practice location:
  • Phone: 602-584-9860
  • Fax: 602-715-1135
Mailing address:
  • Phone:
  • 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 Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MALKA HERSKO
Title or Position: DIRECTOR
Credential: MS CCC SLP
Phone: 602-584-9860