MEDICARE: AUSOME KIDZ THERAPEUTIC SERVICES

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	261QD1600X	Developmental Disabilities Clinic/Center	1-14-17417

General Provider Information

NPI Number	:	1437533049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSOME KIDZ THERAPEUTIC SERVICES

Provider Business Mailing Address
First Line	:	1001 N ROAN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-4669
Country	:	US
Telephone Number	:	423-676-6317
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 N ROAN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-4669
Country	:	US
Telephone Number	:	423-676-6317
Fax Number	:	866-468-5489

Authorized Official
Title or Position	:	OWNER
Name	:	DESIREA SATTERWHITE
Credential	:	BCBA
Telephone Number	:	423-676-6317

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	07/16/2015

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