Provider Demographics
NPI:1578721676
Name:CENTER FOR AUTISM & PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:CENTER FOR AUTISM & PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-306-5644
Mailing Address - Street 1:300 NORTHGATE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3482
Mailing Address - Country:US
Mailing Address - Phone:336-306-5644
Mailing Address - Fax:336-499-6049
Practice Address - Street 1:300 NORTHGATE PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3482
Practice Address - Country:US
Practice Address - Phone:336-306-5644
Practice Address - Fax:336-499-6049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2602103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302082Medicaid