Provider Demographics
NPI:1053888164
Name:THE AUTISM SPARK LLC
Entity type:Organization
Organization Name:THE AUTISM SPARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CHIEF EXECUTIVE OFFICER(CO-CEO)
Authorized Official - Prefix:MISS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AZU
Authorized Official - Suffix:
Authorized Official - Credentials:BSC
Authorized Official - Phone:774-232-4597
Mailing Address - Street 1:30 STEFANIAK AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01570-2032
Mailing Address - Country:US
Mailing Address - Phone:774-232-4597
Mailing Address - Fax:
Practice Address - Street 1:30 STEFANIAK AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:MA
Practice Address - Zip Code:01570-2032
Practice Address - Country:US
Practice Address - Phone:774-232-4597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty