Provider Demographics
NPI:1275904609
Name:AUTASTIC AVENUES LLC
Entity type:Organization
Organization Name:AUTASTIC AVENUES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH/LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:804-301-8428
Mailing Address - Street 1:5911 WILLOW CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:804-301-8428
Mailing Address - Fax:
Practice Address - Street 1:1301 ROBIN HOOD ROAD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227
Practice Address - Country:US
Practice Address - Phone:804-301-8428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202001777235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty