Provider Demographics
NPI:1598007171
Name:AUTISM CENTER OF NORTHERN MICHIGAN
Entity Type:Organization
Organization Name:AUTISM CENTER OF NORTHERN MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:MS BCBA
Authorized Official - Phone:231-497-0555
Mailing Address - Street 1:990 GARFIELD WOODS DR STE B
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-5160
Mailing Address - Country:US
Mailing Address - Phone:231-497-0555
Mailing Address - Fax:
Practice Address - Street 1:990 GARFIELD WOODS DR STE B
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-5160
Practice Address - Country:US
Practice Address - Phone:231-497-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-09-5852251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health