Provider Demographics
NPI:1538689153
Name:WOODBRIDGE AUTISM CENTER, PLLC
Entity Type:Organization
Organization Name:WOODBRIDGE AUTISM CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:SARAH
Authorized Official - Last Name:DAVLANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW, BCBA
Authorized Official - Phone:919-502-1450
Mailing Address - Street 1:2054 KILDAIRE FARM RD # 234
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-6614
Mailing Address - Country:US
Mailing Address - Phone:919-502-1450
Mailing Address - Fax:
Practice Address - Street 1:101 GLENHIGH CT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5200
Practice Address - Country:US
Practice Address - Phone:919-502-1450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-24
Last Update Date:2017-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-16-23002103K00000X
NCC0092791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty