Provider Demographics
NPI:1912034232
Name:AUTISM SERVICES CENTER
Entity Type:Organization
Organization Name:AUTISM SERVICES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-525-8014
Mailing Address - Street 1:10 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-0028
Mailing Address - Country:US
Mailing Address - Phone:304-525-8014
Mailing Address - Fax:304-525-8026
Practice Address - Street 1:10 6TH AVE W
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-0028
Practice Address - Country:US
Practice Address - Phone:304-525-8014
Practice Address - Fax:304-525-8026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0023400001Medicaid