Provider Demographics
NPI:1487077210
Name:AUTISM1ON1
Entity type:Organization
Organization Name:AUTISM1ON1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEGGAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GHISHIJOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-885-5044
Mailing Address - Street 1:158 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:MA
Mailing Address - Zip Code:01562-2260
Mailing Address - Country:US
Mailing Address - Phone:508-762-8393
Mailing Address - Fax:
Practice Address - Street 1:158 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:MA
Practice Address - Zip Code:01562-2260
Practice Address - Country:US
Practice Address - Phone:508-762-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty