Provider Demographics
NPI:1376780478
Name:AUTIS-IMAGINATION LLC
Entity Type:Organization
Organization Name:AUTIS-IMAGINATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SLP
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:816-213-6173
Mailing Address - Street 1:1500 NW MOCK AVE # C
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3095
Mailing Address - Country:US
Mailing Address - Phone:816-213-6173
Mailing Address - Fax:816-229-6997
Practice Address - Street 1:1500 NW MOCK AVE # C
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-3095
Practice Address - Country:US
Practice Address - Phone:816-213-6173
Practice Address - Fax:816-229-6997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-11
Last Update Date:2009-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856253109Medicaid