Provider Demographics
NPI:1225789001
Name:MOON AUTISM CENTER
Entity Type:Organization
Organization Name:MOON AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUZWIK
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:310-488-2814
Mailing Address - Street 1:609 S MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 S MEADOWBROOK LN
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-2829
Practice Address - Country:US
Practice Address - Phone:720-441-8288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty