Healthcare Provider Details

I. General information

NPI: 1922329341
Provider Name (Legal Business Name): INTERNATIONAL CONSULTANT OF HEALTH AND EDUCATIONAL PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CAUGHMAN RIDGE RD
COLUMBIA SC
29209-3114
US

IV. Provider business mailing address

108 CAUGHMAN RIDGE RD
COLUMBIA SC
29209-3114
US

V. Phone/Fax

Practice location:
  • Phone: 803-477-7928
  • Fax:
Mailing address:
  • Phone: 803-477-7928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAKA ABDUL MOUSTAFA I
Title or Position: CEO
Credential: PH.D
Phone: 803-477-7928