Healthcare Provider Details

I. General information

NPI: 1265009641
Provider Name (Legal Business Name): MAYA NECOLE SKINNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2021
Last Update Date: 06/05/2021
Certification Date: 06/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 S LAKE DR
LEXINGTON SC
29073-3720
US

IV. Provider business mailing address

605 ANGEL OAK LN
COLUMBIA SC
29229-7469
US

V. Phone/Fax

Practice location:
  • Phone: 803-726-9400
  • Fax:
Mailing address:
  • Phone: 803-295-1591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14292
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: