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General NPI Number Information
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NPI Number | 1457756595
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Entity Type | Organization
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Legal Business Name | FAMILYPATH AUTISM SERVICES, LLC
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Dates
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Enumeration Date | 10/31/2014
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Last Update Date | 05/05/2015
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Provider Practice Location Address
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Address Line | 575 DONOFRIO DR STE 101
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City | MADISON
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State | WI
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Zip | 53719-2832
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Country | US
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Telephone | 608-512-0780
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Fax | 608-841-1059
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Provider Business Mailing Address
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Address Line | 575 DONOFRIO DR STE 101
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City | MADISON
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State | WI
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Zip | 53719-2832
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Country | US
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Telephone | 608-512-0780
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Fax | 608-841-1059
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Authorized Official
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Title or Position | MEMBER
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Name | CONNIE THOMAS
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Credential |
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Telephone | 608-513-2272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 222957
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 674124
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License Number State | WI
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