Healthcare Provider Details

I. General information

NPI: 1912034232
Provider Name (Legal Business Name): AUTISM SERVICES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 6TH AVE W
HUNTINGTON WV
25701-0028
US

IV. Provider business mailing address

10 6TH AVE W
HUNTINGTON WV
25701-0028
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-8014
  • Fax: 304-525-8026
Mailing address:
  • Phone: 304-525-8014
  • Fax: 304-525-8026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number35
License Number StateWV

VIII. Authorized Official

Name: MR. MIKE J GRADY
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 305-525-8014