=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780961706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLESTON AUTISM ACADEMY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2011
-----------------------------------------------------
Last Update Date | 11/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 480 JESSEN LN STE D
-----------------------------------------------------
City | WANDO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29492-7915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-881-0330
-----------------------------------------------------
Fax | 843-405-7020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 480 JESSEN LN STE D
-----------------------------------------------------
City | WANDO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29492-7915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-881-0330
-----------------------------------------------------
Fax | 843-405-7020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD PRESIDENT
-----------------------------------------------------
Name | LAURA MISENHELTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-881-0330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 3529
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 4491
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------