=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669274841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTISM DIAGNOSTICS SERVICES OF NORTH CAROLINA, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2025
-----------------------------------------------------
Last Update Date | 03/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20830 TORRENCE CHAPEL RD STE 204
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-0320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-295-3276
-----------------------------------------------------
Fax | 888-588-2752
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1333 S MAYFLOWER AVE STE 220
-----------------------------------------------------
City | MONROVIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91016-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-241-6780
-----------------------------------------------------
Fax | 888-588-2752
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. IVORY O'ROURKE
-----------------------------------------------------
Credential | CP
-----------------------------------------------------
Telephone | 818-309-0969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------