Provider Demographics
NPI:1629512652
Name:NORTHSHORE AUTISM CENTER, LLC
Entity Type:Organization
Organization Name:NORTHSHORE AUTISM CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVRE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA
Authorized Official - Phone:985-502-1884
Mailing Address - Street 1:345 FOREST BROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-8474
Mailing Address - Country:US
Mailing Address - Phone:985-502-1884
Mailing Address - Fax:
Practice Address - Street 1:800 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5328
Practice Address - Country:US
Practice Address - Phone:985-502-1884
Practice Address - Fax:504-617-7811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency