Provider Demographics
NPI:1336579754
Name:INTERDISCIPLINARY COMMUNITY AUTISM NETWORK, INC
Entity type:Organization
Organization Name:INTERDISCIPLINARY COMMUNITY AUTISM NETWORK, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:SOUDER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, HSPP
Authorized Official - Phone:260-498-9933
Mailing Address - Street 1:2599 COUNTY ROAD 72
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-9624
Mailing Address - Country:US
Mailing Address - Phone:260-498-9933
Mailing Address - Fax:
Practice Address - Street 1:409 E COOK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-3600
Practice Address - Country:US
Practice Address - Phone:260-498-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103TS0200X, 1041C0700X, 171M00000X, 222Q00000X, 225100000X, 235Z00000X, 251S00000X
IN20042225A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty