=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316700677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUIDANCE PEDIATRICS AND AUTISM SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2024
-----------------------------------------------------
Last Update Date | 01/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6657 W COUNTY ROAD 900 N
-----------------------------------------------------
City | BRAZIL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47834-7952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-239-6293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8465 KEYSTONE CROSSING SUITE 115 #1201
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-239-6293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALYSSA PETROWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-239-6293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------