Provider Demographics
NPI:1457941908
Name:PALMETTO AUTISM SERVICES
Entity Type:Organization
Organization Name:PALMETTO AUTISM SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/BCBA
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:803-487-8508
Mailing Address - Street 1:925 ROXBURGH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-5505
Mailing Address - Country:US
Mailing Address - Phone:803-487-8508
Mailing Address - Fax:
Practice Address - Street 1:925 ROXBURGH AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-5505
Practice Address - Country:US
Practice Address - Phone:803-487-8508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty