Provider Demographics
NPI:1568624104
Name:CHRYSALIS AUTISM CENTER
Entity Type:Organization
Organization Name:CHRYSALIS AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOBEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:PRESLER
Authorized Official - Suffix:
Authorized Official - Credentials:BCABA
Authorized Official - Phone:803-367-2261
Mailing Address - Street 1:1547 CHERRY RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2616
Mailing Address - Country:US
Mailing Address - Phone:803-792-0771
Mailing Address - Fax:
Practice Address - Street 1:410 OAKLAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730
Practice Address - Country:US
Practice Address - Phone:803-792-0771
Practice Address - Fax:803-656-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0-04-1396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEXG309Medicaid