Basic Information
| Provider Information | |||||||||
| NPI: | 1275934622 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUTISM CONTINUUM THERAPIES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N BRAND BLVD | ||||||||
| Address2: | #1000 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912031906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182416780 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Practice Location | |||||||||
| Address1: | 8500 EXECUTIVE PARK AVE | ||||||||
| Address2: | SUITE 408 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220312225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552953276 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2014 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 8182416780 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-00-0010 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-07-3957 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-00-0010 | 01 | CA | BCBA-D | OTHER |