Provider Demographics
NPI:1982059069
Name:AUTISM SERVICES OF MICHIANA LLC
Entity Type:Organization
Organization Name:AUTISM SERVICES OF MICHIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORZLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:574-383-0107
Mailing Address - Street 1:4201 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-3848
Mailing Address - Country:US
Mailing Address - Phone:574-383-0107
Mailing Address - Fax:
Practice Address - Street 1:4201 COTTAGE AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-3848
Practice Address - Country:US
Practice Address - Phone:574-383-0107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-16-21690103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty