Provider Demographics
NPI:1972790582
Name:AUTISM SERVICE PROVIDER & BEYOND, LLC
Entity Type:Organization
Organization Name:AUTISM SERVICE PROVIDER & BEYOND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:630-639-1655
Mailing Address - Street 1:800 W 5TH AVE
Mailing Address - Street 2:STE. 106 F/G
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8965
Mailing Address - Country:US
Mailing Address - Phone:630-639-1655
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:STE. 106 F/G
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8965
Practice Address - Country:US
Practice Address - Phone:630-639-1655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103K00000X
ILKW48321203P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty