Provider Demographics
NPI:1083012447
Name:SO LOVE AUTISTIC CENTER
Entity Type:Organization
Organization Name:SO LOVE AUTISTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VENUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LBS
Authorized Official - Phone:610-446-3680
Mailing Address - Street 1:335 BISHOP HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3255
Mailing Address - Country:US
Mailing Address - Phone:610-446-3680
Mailing Address - Fax:484-652-2185
Practice Address - Street 1:335 BISHOP HOLLOW RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3255
Practice Address - Country:US
Practice Address - Phone:610-446-3680
Practice Address - Fax:484-652-2185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
PACW016808251S00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103048922-0003Medicaid