Provider Demographics
NPI:1932643590
Name:TOTAL SPECTRUM AUTISM SERVICES LLC
Entity Type:Organization
Organization Name:TOTAL SPECTRUM AUTISM SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATERRELL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-767-9405
Mailing Address - Street 1:515 MAPLEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-9261
Mailing Address - Country:US
Mailing Address - Phone:502-767-9405
Mailing Address - Fax:812-727-5522
Practice Address - Street 1:515 MAPLEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:IN
Practice Address - Zip Code:47122-9261
Practice Address - Country:US
Practice Address - Phone:502-767-9405
Practice Address - Fax:812-727-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002390A101YM0800X
KY129006103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1235558628OtherCOMMERCIAL
KY1013002443OtherCOMMERCIAL
IN1790917060OtherCOMMERCIAL