MEDICARE: PEE-WEE'S BEHAVIORAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1629769583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEE-WEE'S BEHAVIORAL SERVICES LLC

Provider Business Mailing Address
First Line	:	2952 LITTLE BETHEL RD
Second Line	:
City	:	GREEN SEA
State	:	SC
Zip	:	29545-3729
Country	:	US
Telephone Number	:	843-489-1025
Fax Number	:

Provider Business Practice Location Address
First Line	:	2952 LITTLE BETHEL RD
Second Line	:
City	:	GREEN SEA
State	:	SC
Zip	:	29545-3729
Country	:	US
Telephone Number	:	843-489-1025
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SEFA BAILEY
Credential	:	BCBA 1-21-49684
Telephone Number	:	843-489-1025

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/19/2023

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