Healthcare Provider Details

I. General information

NPI: 1528108073
Provider Name (Legal Business Name): SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EXECUTIVE CENTER DR SANTEE BUILDING SUITE210
COLUMBIA SC
29210-8407
US

IV. Provider business mailing address

PO BOX 21069
COLUMBIA SC
29221-1069
US

V. Phone/Fax

Practice location:
  • Phone: 803-896-4751
  • Fax: 803-896-8473
Mailing address:
  • Phone: 803-896-4751
  • Fax: 803-896-8473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. MIA L RICHARDSON
Title or Position: MEDICAID PROJECT ADMINISTRATOR
Credential:
Phone: 803-896-4751