Provider Demographics
NPI:1720514938
Name:CRESCENT CHILD DEVELOPMENT SERVICES, LLC
Entity Type:Organization
Organization Name:CRESCENT CHILD DEVELOPMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GREGORI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-813-1538
Mailing Address - Street 1:966 GOVERNORS CT
Mailing Address - Street 2:MOUNT PLEASANT
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9257
Mailing Address - Country:US
Mailing Address - Phone:843-813-1538
Mailing Address - Fax:888-813-3318
Practice Address - Street 1:2810 ASHLEY PHOSPHATE RD
Practice Address - Street 2:B-11
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6405
Practice Address - Country:US
Practice Address - Phone:843-813-1538
Practice Address - Fax:888-813-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106E00000X
SC2212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty