Provider Demographics
NPI:1568730281
Name:EASTERN MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:EASTERN MICHIGAN UNIVERSITY
Other - Org Name:AUTISM COLLABORATIVE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KASTLE-RUETHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-487-2890
Mailing Address - Street 1:1055 CORNELL RD
Mailing Address - Street 2:FLETCHER BUILDING, ACC MAIN OFFICE
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 CORNELL RD
Practice Address - Street 2:FLETCHER BUILDING,
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1657
Practice Address - Country:US
Practice Address - Phone:734-485-2890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1780989020103TC0700X
MI23317193174400000X
MI1699070656174400000X
MI5201007984174400000X
MI1215113246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty