Provider Demographics
NPI:1023376217
Name:AUTISM SPECIALTY GROUP LLC
Entity Type:Organization
Organization Name:AUTISM SPECIALTY GROUP LLC
Other - Org Name:AUTISM SPECIALTY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RONACHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-553-6663
Mailing Address - Street 1:PO BOX 12618
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-2618
Mailing Address - Country:US
Mailing Address - Phone:305-767-1924
Mailing Address - Fax:
Practice Address - Street 1:144 NW 37TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-3111
Practice Address - Country:US
Practice Address - Phone:305-767-1924
Practice Address - Fax:305-673-5917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-10-7874103K00000X
261QM0855X, 261QD1600X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017552000Medicaid