MEDICARE: SYNERGY 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	GRANDFATHERED-IN	OR

General Provider Information

NPI Number	:	1528437142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYNERGY AUTISM CENTER, LLC

Provider Business Mailing Address
First Line	:	7739 SW CAPITOL HWY
Second Line	:	#220
City	:	PORTLAND
State	:	OR
Zip	:	97219-2571
Country	:	US
Telephone Number	:	503-432-8760
Fax Number	:

Provider Business Practice Location Address
First Line	:	7739 SW CAPITOL HWY
Second Line	:	#220
City	:	PORTLAND
State	:	OR
Zip	:	97219-2571
Country	:	US
Telephone Number	:	503-432-8760
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	BARBARA AVILA
Credential	:
Telephone Number	:	503-432-8760

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	09/24/2015

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