Healthcare Provider Details

I. General information

NPI: 1801205265
Provider Name (Legal Business Name): GOOD KIDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2014
Last Update Date: 08/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 N MAIN ST
COLUMBIA SC
29203-4520
US

IV. Provider business mailing address

112 BEAVER CREEK DR
COLUMBIA SC
29223-7750
US

V. Phone/Fax

Practice location:
  • Phone: 803-216-5397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ROBERT WYLIE
Title or Position: DIRECTOR
Credential:
Phone: 803-530-0277