Healthcare Provider Details

I. General information

NPI: 1972059251
Provider Name (Legal Business Name): MIYANNA MCINTYRE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 8TH DIVISION RD
COLUMBIA SC
29207-5700
US

IV. Provider business mailing address

4500 8TH DIVISION RD
COLUMBIA SC
29207-5700
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2935
  • Fax: 803-751-0557
Mailing address:
  • Phone: 803-751-2935
  • Fax: 803-751-0557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC011689
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: