Provider Demographics
NPI:1649508912
Name:EMERALD COAST AUTISM CENTER
Entity type:Organization
Organization Name:EMERALD COAST AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACI
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSED, BCBA
Authorized Official - Phone:850-279-3000
Mailing Address - Street 1:200 PARTIN DR N
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1244
Mailing Address - Country:US
Mailing Address - Phone:850-279-3000
Mailing Address - Fax:850-678-0922
Practice Address - Street 1:200 PARTIN DR N
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1244
Practice Address - Country:US
Practice Address - Phone:850-279-3000
Practice Address - Fax:850-678-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty