=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285204495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFECT PIECES AUTISM CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2021
-----------------------------------------------------
Last Update Date | 06/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8455 HIGHWAY 85 STE B
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-5115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-442-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8455 HIGHWAY 85 STE B
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-5115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-442-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. DEBORAH DOUGLASS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-442-5550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------