MEDICARE: FAITH & FLY PSYCHIATRIC PRACTICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B919	OTHER		PTAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467038828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAITH & FLY PSYCHIATRIC PRACTICE, LLC

Provider Business Mailing Address
First Line	:	3326 JACKSON CREEK RD
Second Line	:
City	:	WINNSBORO
State	:	SC
Zip	:	29180-6600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2424 INDIA HOOK RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-2784
Country	:	US
Telephone Number	:	803-801-0878
Fax Number	:

Authorized Official
Title or Position	:	PMHNP-BC
Name	:	MARY GOLDIN
Credential	:
Telephone Number	:	803-801-0878

Provider Enumeration Date	:	03/24/2021
Last Update Date	:	03/24/2021

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