=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164017851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHIGAN AUTISM SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2021
-----------------------------------------------------
Last Update Date | 03/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13977 THORNAPPLE LN
-----------------------------------------------------
City | PERRY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48872-9116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-615-4513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13977 THORNAPPLE LN
-----------------------------------------------------
City | PERRY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48872-9116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-615-4513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | KRISTINE BOOZER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-615-4513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------