Healthcare Provider Details

I. General information

NPI: 1356664437
Provider Name (Legal Business Name): CHARLESTON AUTISM ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 10/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 JESSEN LN STE D
WANDO SC
29492-7915
US

IV. Provider business mailing address

480 JESSEN LN STE D
WANDO SC
29492-7915
US

V. Phone/Fax

Practice location:
  • Phone: 843-881-0330
  • Fax: 843-405-7020
Mailing address:
  • Phone: 843-881-0330
  • Fax: 843-405-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number3529
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4491
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA TODD MISENHELTER
Title or Position: PRESIDENT, BOARD OF TRUSTEES
Credential:
Phone: 843-881-0330