Healthcare Provider Details

I. General information

NPI: 1679782205
Provider Name (Legal Business Name): MIDLANDS PSYCHIATRIC SERVICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ALPINE CIR
COLUMBIA SC
29223-6385
US

IV. Provider business mailing address

125 ALPINE CIR
COLUMBIA SC
29223-6385
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-3548
  • Fax: 803-779-7055
Mailing address:
  • Phone: 803-779-3548
  • Fax: 803-779-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLIE BRYAN MOZINGO
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 803-779-3548