MEDICARE: WHITEROCK AUTISM THERAPY CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2080P0008X	Pediatric Neurodevelopmental Disabilities Physician
2	225X00000X	Occupational Therapist
3	225XP0200X	Pediatric Occupational Therapist
4	235Z00000X	Speech-Language Pathologist
5	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1275218554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITEROCK AUTISM THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	401 W WASHINGTON ST
Second Line	:
City	:	ROCKWALL
State	:	TX
Zip	:	75087-3615
Country	:	US
Telephone Number	:	972-722-3892
Fax Number	:	214-602-2729

Provider Business Practice Location Address
First Line	:	1151 N BUCKNER BLVD STE 301
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75218-3405
Country	:	US
Telephone Number	:	972-722-3892
Fax Number	:	214-602-2729

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CYNTHIA MEJIA
Credential	:
Telephone Number	:	972-722-3892

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	06/15/2023

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