Healthcare Provider Details

I. General information

NPI: 1902104276
Provider Name (Legal Business Name): MINDS MOVING FORWARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 CHEROKEE ST
ORANGEBURG SC
29115-7635
US

IV. Provider business mailing address

PO BOX 1629
ORANGEBURG SC
29116-1629
US

V. Phone/Fax

Practice location:
  • Phone: 803-308-2954
  • Fax:
Mailing address:
  • Phone: 803-308-2954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateSC

VIII. Authorized Official

Name: MR. DEMAR GILLIARD
Title or Position: DIRECTOR OF OFFICE
Credential:
Phone: 803-308-2954