Provider Demographics
NPI:1255715074
Name:EMERALD COAST AUTISM CENTER
Entity type:Organization
Organization Name:EMERALD COAST AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:850-279-3000
Mailing Address - Street 1:315 EDGE AVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1807
Mailing Address - Country:US
Mailing Address - Phone:850-279-3000
Mailing Address - Fax:850-389-2269
Practice Address - Street 1:315 EDGE AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1807
Practice Address - Country:US
Practice Address - Phone:850-279-3000
Practice Address - Fax:850-389-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11518965251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health