Provider Demographics
NPI:1689010753
Name:AUTISM SERVICES OF MECKLENBURG CO. INC.
Entity Type:Organization
Organization Name:AUTISM SERVICES OF MECKLENBURG CO. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:MARCELLOUS
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA
Authorized Official - Phone:704-392-9220
Mailing Address - Street 1:2211 EXECUTIVE ST STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-3655
Mailing Address - Country:US
Mailing Address - Phone:704-392-9220
Mailing Address - Fax:704-392-9221
Practice Address - Street 1:2223 EXECUTIVE ST
Practice Address - Street 2:SUITE E
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-3653
Practice Address - Country:US
Practice Address - Phone:704-392-9220
Practice Address - Fax:704-392-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-1083251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health