=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154060689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTISM SPECIALTY GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2022
-----------------------------------------------------
Last Update Date | 06/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 NW 37TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33127-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-767-1924
-----------------------------------------------------
Fax | 305-673-5917
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12618
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33101-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-767-1924
-----------------------------------------------------
Fax | 305-673-5917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | RAQUEL RONACHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-553-6663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------