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General NPI Number Information
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NPI Number | 1275042269
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Entity Type | Organization
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Legal Business Name | RISING PALMS BEHAVIORAL PEDIATRICS
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Dates
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Enumeration Date | 09/22/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 12077 DIAMOND SPRINGS DR
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City | JACKSONVILLE
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State | FL
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Zip | 32246-0597
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Country | US
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Telephone | 256-504-8841
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Fax |
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Provider Business Mailing Address
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Address Line | 12077 DIAMOND SPRINGS DR
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City | JACKSONVILLE
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State | FL
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Zip | 32246-0597
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Country | US
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Telephone | 256-504-8841
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MRS. ASHLEY VICKERY KISER
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Credential | MA, BCBA
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Telephone | 256-504-8841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-12-10529
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License Number State | FL
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