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General NPI Number Information
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NPI Number | 1598007171
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Entity Type | Organization
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Legal Business Name | AUTISM CENTER OF NORTHERN MICHIGAN
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Dates
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Enumeration Date | 03/21/2013
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Last Update Date | 03/21/2013
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Provider Practice Location Address
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Address Line | 990 GARFIELD WOODS DR STE B
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City | TRAVERSE CITY
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State | MI
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Zip | 49686-5160
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Country | US
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Telephone | 231-497-0555
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Fax |
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Provider Business Mailing Address
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Address Line | 990 GARFIELD WOODS DR STE B
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City | TRAVERSE CITY
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State | MI
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Zip | 49686-5160
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Country | US
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Telephone | 231-497-0555
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JORDAN P BOUDREAU
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Credential | MS BCBA
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Telephone | 231-497-0555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1-09-5852
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License Number State | MI
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