Provider Demographics
NPI:1700617545
Name:ORIGIN AUTISM DIAGNOSTIC CLINIC INC
Entity type:Organization
Organization Name:ORIGIN AUTISM DIAGNOSTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEIGHTON
Authorized Official - Middle Name:B
Authorized Official - Last Name:DEES
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:251-554-4525
Mailing Address - Street 1:8760 WINFORD WAY
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36619-4318
Mailing Address - Country:US
Mailing Address - Phone:251-554-4525
Mailing Address - Fax:
Practice Address - Street 1:6349 PICCADILLY SQUARE DR STE B
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5103
Practice Address - Country:US
Practice Address - Phone:251-554-4525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty