=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720514938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESCENT CHILD DEVELOPMENT SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2017
-----------------------------------------------------
Last Update Date | 05/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2810 ASHLEY PHOSPHATE RD B-11
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29418-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-813-1538
-----------------------------------------------------
Fax | 888-813-3318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 966 GOVERNORS CT MOUNT PLEASANT
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29464-9257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-813-1538
-----------------------------------------------------
Fax | 888-813-3318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | MS. TARA MARIE GREGORI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-813-1538
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2212
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------