Healthcare Provider Details

I. General information

NPI: 1144926783
Provider Name (Legal Business Name): KRYSTAL VELEKA MCMULLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SC-HWY 252
ANDERSON SC
29621
US

IV. Provider business mailing address

2414 BULL ST STE 201
COLUMBIA SC
29201-1906
US

V. Phone/Fax

Practice location:
  • Phone: 864-231-2600
  • Fax:
Mailing address:
  • Phone: 803-636-5408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: