MEDICARE: THE AUTISM GROUP, INC.

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	174400000X	Specialist	5056	CA
2	174400000X	Specialist	6687	CA

General Provider Information

NPI Number	:	1619265311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE AUTISM GROUP, INC.

Provider Business Mailing Address
First Line	:	9466 BLACK MOUNTAIN RD
Second Line	:	SUITE 100
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4550
Country	:	US
Telephone Number	:	858-689-2027
Fax Number	:	858-689-2027

Provider Business Practice Location Address
First Line	:	9466 BLACK MOUNTAIN RD
Second Line	:	SUITE 100
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4550
Country	:	US
Telephone Number	:	858-689-2027
Fax Number	:	858-689-2027

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	BROOKE E. WAGNER
Credential	:	M.A.
Telephone Number	:	858-689-2027

Provider Enumeration Date	:	07/14/2011
Last Update Date	:	08/12/2011

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