Provider Demographics
NPI:1477830503
Name:PENINSULA ACADEMY FOR AUTISM
Entity Type:Organization
Organization Name:PENINSULA ACADEMY FOR AUTISM
Other - Org Name:PENINSULA SCHOOL FOR AUTISM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:RANDALL JOHNSON
Authorized Official - Last Name:MROWIEC
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:757-223-0558
Mailing Address - Street 1:12749 NETTLES DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1804
Mailing Address - Country:US
Mailing Address - Phone:757-223-0558
Mailing Address - Fax:757-223-0559
Practice Address - Street 1:12749 NETTLES DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1804
Practice Address - Country:US
Practice Address - Phone:757-223-0558
Practice Address - Fax:757-223-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty