Healthcare Provider Details

I. General information

NPI: 1093374605
Provider Name (Legal Business Name): MHA-SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 COMMERCE DR
CAYCE SC
29033-1524
US

IV. Provider business mailing address

2105 COMMERCE DR
CAYCE SC
29033-1524
US

V. Phone/Fax

Practice location:
  • Phone: 803-796-6179
  • Fax:
Mailing address:
  • Phone: 803-796-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AARON BROWN
Title or Position: PROGRAM MANAGER
Credential: MSW
Phone: 803-796-6179