MEDICARE: RADIANT AUTISM CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1184223737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANT AUTISM CENTER, LLC

Provider Business Mailing Address
First Line	:	2831 ELDORADO PKWY STE 106
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75033-7438
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2831 ELDORADO PKWY STE 106
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75033-7438
Country	:	US
Telephone Number	:	214-778-1153
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTOPHER THOMAS CARLSON
Credential	:
Telephone Number	:	214-778-1153

Provider Enumeration Date	:	10/23/2020
Last Update Date	:	08/07/2023

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