Healthcare Provider Details

I. General information

NPI: 1336345255
Provider Name (Legal Business Name): SHAKA ABDUL MOUSTAFA I PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
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 TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: