Provider Demographics
NPI:1972854693
Name:AUTISM SERVICES OF MECKLENBURG COUNTY, INC.
Entity Type:Organization
Organization Name:AUTISM SERVICES OF MECKLENBURG COUNTY, 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
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-3661
Mailing Address - Country:US
Mailing Address - Phone:704-392-9220
Mailing Address - Fax:704-392-9221
Practice Address - Street 1:4319 MANTLE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7243
Practice Address - Country:US
Practice Address - Phone:704-567-8082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-167315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340602BMedicaid