Healthcare Provider Details

I. General information

NPI: 1942833942
Provider Name (Legal Business Name): MOUA AUTISM SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 PLAZA DR APT 104
MADISON WI
53719-3853
US

IV. Provider business mailing address

530 PLAZA DR APT 104
MADISON WI
53719-3853
US

V. Phone/Fax

Practice location:
  • Phone: 608-422-3575
  • Fax:
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 Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: PIYAPORN MOUA
Title or Position: EXECUTIVE DIRECTOR
Credential: BCBA
Phone: 608-422-3575