Healthcare Provider Details

I. General information

NPI: 1356621817
Provider Name (Legal Business Name): CRESCENT CHILD DEVELOPMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2011
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 GOVERNORS CT
MOUNT PLEASANT SC
29464-9257
US

IV. Provider business mailing address

966 GOVERNORS CT
MOUNT PLEASANT SC
29464-9257
US

V. Phone/Fax

Practice location:
  • Phone: 843-813-1538
  • Fax: 888-813-3318
Mailing address:
  • Phone: 843-813-1538
  • Fax: 888-813-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2212
License Number StateSC

VIII. Authorized Official

Name: MS. TARA MARIE GREGORI
Title or Position: DIRECTOR
Credential: MSP, CCC-SLP, BCBA
Phone: 843-813-1538