Provider Demographics
NPI:1568801017
Name:COLLINS LAKE AUTISM CENTER
Entity Type:Organization
Organization Name:COLLINS LAKE AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SMABY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-630-0827
Mailing Address - Street 1:710 GILDERSLEEVE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2636
Mailing Address - Country:US
Mailing Address - Phone:281-630-0827
Mailing Address - Fax:
Practice Address - Street 1:246 ENCINAL ROAD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:NM
Practice Address - Zip Code:87715
Practice Address - Country:US
Practice Address - Phone:281-630-0827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities