Healthcare Provider Details

I. General information

NPI: 1861263089
Provider Name (Legal Business Name): MINDSHIFTERS SOLUTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 LAURENS AVE S
FAIRFAX SC
29827-5302
US

IV. Provider business mailing address

437 LAURENS AVE S
FAIRFAX SC
29827-5302
US

V. Phone/Fax

Practice location:
  • Phone: 803-824-9558
  • Fax:
Mailing address:
  • Phone: 803-824-9558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. YULANDAR SUE SIMMONS
Title or Position: OWNER
Credential:
Phone: 803-824-9558