Provider Demographics
NPI:1184346066
Name:SDS BEHAVIORAL CONSULTING LLC
Entity type:Organization
Organization Name:SDS BEHAVIORAL CONSULTING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIZZLEY-STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:803-459-8022
Mailing Address - Street 1:194 CYPRESS FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-8441
Mailing Address - Country:US
Mailing Address - Phone:803-459-8022
Mailing Address - Fax:
Practice Address - Street 1:194 CYPRESS FOREST DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-8441
Practice Address - Country:US
Practice Address - Phone:803-459-8022
Practice Address - Fax:803-845-3510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-16
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCBA1197Medicaid