Healthcare Provider Details

I. General information

NPI: 1063056828
Provider Name (Legal Business Name): FULL SPECTRUM ABA OF SOUTH CAROLINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 RIVERS AVE STE 100
NORTH CHARLESTON SC
29406-4809
US

IV. Provider business mailing address

6650 RIVERS AVE STE 100
NORTH CHARLESTON SC
29406-4809
US

V. Phone/Fax

Practice location:
  • Phone: 813-926-5454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: COLLIN EDWARD STREETMAN
Title or Position: OWNER
Credential: BCBA
Phone: 813-926-5454