Provider Demographics
NPI:1104352038
Name:SPECIALIZED THERAPIES FOR AUTISM AND RELATED SERVICES
Entity type:Organization
Organization Name:SPECIALIZED THERAPIES FOR AUTISM AND RELATED SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:BARTLETT
Authorized Official - Last Name:HICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA
Authorized Official - Phone:916-397-4045
Mailing Address - Street 1:3202 MALLARD LN
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7795
Mailing Address - Country:US
Mailing Address - Phone:916-397-4045
Mailing Address - Fax:
Practice Address - Street 1:3202 MALLARD LN
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7795
Practice Address - Country:US
Practice Address - Phone:916-397-4045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-155103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty