Provider Demographics
NPI:1477797801
Name:CENTER FOR AUTISM SPECTRUM DISORDERS
Entity Type:Organization
Organization Name:CENTER FOR AUTISM SPECTRUM DISORDERS
Other - Org Name:THE AUTISM PROGRAM AT SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Other - Org Type:Other Name
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-453-7130
Mailing Address - Street 1:625 WHAM DR
Mailing Address - Street 2:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-4313
Mailing Address - Country:US
Mailing Address - Phone:618-536-2122
Mailing Address - Fax:618-453-7178
Practice Address - Street 1:625 WHAM DR -MAILCODE 6607
Practice Address - Street 2:SOUTHERN ILLINOIS UNIVERSITY CARBONDALE
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-4313
Practice Address - Country:US
Practice Address - Phone:618-536-2122
Practice Address - Fax:618-453-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center