Provider Demographics
NPI:1174298319
Name:SANDIA AUTISM SERVICES LLC
Entity Type:Organization
Organization Name:SANDIA AUTISM SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:I
Authorized Official - Last Name:WORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:505-274-9018
Mailing Address - Street 1:9123 PALOMAS AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6632
Mailing Address - Country:US
Mailing Address - Phone:505-274-9018
Mailing Address - Fax:
Practice Address - Street 1:9123 PALOMAS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-6632
Practice Address - Country:US
Practice Address - Phone:505-274-9018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty