=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720427875
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARAGON AUTISM SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2013
-----------------------------------------------------
Last Update Date | 06/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 PROGRESS ST SUITE 300
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-479-3889
-----------------------------------------------------
Fax | 540-479-3946
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 FARRISH DR
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401-6642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MRS. DOROTHY H DESCANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-479-3889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------