Provider Demographics
NPI:1801381173
Name:SKYLIGHT AUTISM CENTER
Entity Type:Organization
Organization Name:SKYLIGHT AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGENZA
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:715-571-1566
Mailing Address - Street 1:7505 GUSMAN RD
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2109
Mailing Address - Country:US
Mailing Address - Phone:715-571-1566
Mailing Address - Fax:
Practice Address - Street 1:4601 CAMP PHILLIPS RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-1572
Practice Address - Country:US
Practice Address - Phone:715-571-1566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1-16-24748103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679018022Medicaid