Provider Demographics
NPI:1316261621
Name:SOUTHEAST MISSOURI STATE UNIVERSITY AUTISM CENTER
Entity type:Organization
Organization Name:SOUTHEAST MISSOURI STATE UNIVERSITY AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS-ADKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-651-2408
Mailing Address - Street 1:1 UNIVERSITY PLAZA
Mailing Address - Street 2:MAIL STOP 9450
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4710
Mailing Address - Country:US
Mailing Address - Phone:573-986-4985
Mailing Address - Fax:573-986-4994
Practice Address - Street 1:611 N. FOUNTAIN ST.
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7244
Practice Address - Country:US
Practice Address - Phone:573-986-4985
Practice Address - Fax:573-986-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health