=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326356239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTISM LEARNING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2010
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 N 29TH ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-323-1223
-----------------------------------------------------
Fax | 318-323-1224
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 N 29TH ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-323-1223
-----------------------------------------------------
Fax | 318-323-1224
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MS. LISA GILLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-323-1223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number | 497870
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------