Basic Information
| Provider Information | |||||||||
| NPI: | 1588038079 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELTA ABA THERAPY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DELTA ABA THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 988 COVE POINT LANE | ||||||||
| Address2: | |||||||||
| City: | TEGA CAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552015498 | ||||||||
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| Practice Location | |||||||||
| Address1: | 988 COVE POINT LANE | ||||||||
| Address2: | |||||||||
| City: | TEGA CAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552015498 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | MACHOSE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5857320694 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPES, BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.