Provider Demographics
NPI:1275042269
Name:RISING PALMS BEHAVIORAL PEDIATRICS
Entity Type:Organization
Organization Name:RISING PALMS BEHAVIORAL PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:VICKERY
Authorized Official - Last Name:KISER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:256-504-8841
Mailing Address - Street 1:12077 DIAMOND SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-0597
Mailing Address - Country:US
Mailing Address - Phone:256-504-8841
Mailing Address - Fax:
Practice Address - Street 1:12077 DIAMOND SPRINGS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-0597
Practice Address - Country:US
Practice Address - Phone:256-504-8841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-10529103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty