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General NPI Number Information
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NPI Number | 1245597269
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Entity Type | Organization
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Legal Business Name | EMERALD COAST AUTISM CENTER
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Dates
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Enumeration Date | 04/16/2012
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Last Update Date | 04/16/2012
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Provider Practice Location Address
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Address Line | 200 PARTIN DR N
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City | NICEVILLE
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State | FL
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Zip | 32578-1244
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Country | US
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Telephone | 850-279-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 200 PARTIN DR N
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City | NICEVILLE
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State | FL
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Zip | 32578-1244
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. STACI BERRYMAN
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Credential | BCBA
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Telephone | 850-279-3000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA11523
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License Number State | FL
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