Provider Demographics
NPI:1639802382
Name:AUTISM 360 SUPPORT LLC
Entity Type:Organization
Organization Name:AUTISM 360 SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:JENNY
Authorized Official - Last Name:SLATON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:562-361-8578
Mailing Address - Street 1:11278 LOS ALAMITOS BLVD # 106
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3958
Mailing Address - Country:US
Mailing Address - Phone:562-396-5896
Mailing Address - Fax:
Practice Address - Street 1:5762 BOLSA AVE STE 107
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1172
Practice Address - Country:US
Practice Address - Phone:562-361-8578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-08
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty