Provider Demographics
NPI:1376219691
Name:AUTISMWAVE THERAPY SERVICES
Entity Type:Organization
Organization Name:AUTISMWAVE THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-357-5705
Mailing Address - Street 1:13312 SE 262ND ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-8521
Mailing Address - Country:US
Mailing Address - Phone:206-582-9392
Mailing Address - Fax:
Practice Address - Street 1:13312 SE 262ND ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-8521
Practice Address - Country:US
Practice Address - Phone:206-582-9392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health