Provider Demographics
NPI:1063092989
Name:GIFTED AUTISM SERVICES LLC
Entity type:Organization
Organization Name:GIFTED AUTISM SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LBA, BCBA
Authorized Official - Phone:616-213-2965
Mailing Address - Street 1:4557 13 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8623
Mailing Address - Country:US
Mailing Address - Phone:616-213-2965
Mailing Address - Fax:
Practice Address - Street 1:4557 13 MILE RD NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-8623
Practice Address - Country:US
Practice Address - Phone:616-213-2965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty