MEDICARE: THE GRACIE V. WHITE FOUNDATION FOR AUTISM

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1750165437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GRACIE V. WHITE FOUNDATION FOR AUTISM

Provider Business Mailing Address
First Line	:	4503 BLUE LARGO CT
Second Line	:
City	:	GAHANNA
State	:	OH
Zip	:	43230-2091
Country	:	US
Telephone Number	:	614-620-4273
Fax Number	:

Provider Business Practice Location Address
First Line	:	4503 BLUE LARGO CT
Second Line	:
City	:	GAHANNA
State	:	OH
Zip	:	43230-2091
Country	:	US
Telephone Number	:	614-620-4273
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MRS. GRACIE V WHITE
Credential	:	SOCIAL WORKER
Telephone Number	:	614-620-4273

Provider Enumeration Date	:	08/23/2023
Last Update Date	:	08/23/2023

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