MEDICARE: GHA AUTISM SUPPORTS

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962836460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GHA AUTISM SUPPORTS

Provider Business Mailing Address
First Line	:	PO BOX 2487
Second Line	:
City	:	ALBEMARLE
State	:	NC
Zip	:	28002-2487
Country	:	US
Telephone Number	:	704-982-9600
Fax Number	:	704-982-8155

Provider Business Practice Location Address
First Line	:	20 N 4TH ST
Second Line	:	SUITE 300B
City	:	WILMINGTON
State	:	NC
Zip	:	28401-4553
Country	:	US
Telephone Number	:	704-982-9600
Fax Number	:	704-982-8155

Authorized Official
Title or Position	:	CEO
Name	:	DAWN HARWOOD ALLEN
Credential	:
Telephone Number	:	704-982-9600

Provider Enumeration Date	:	09/03/2013
Last Update Date	:	09/28/2020

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