Healthcare Provider Details

I. General information

NPI: 1588579502
Provider Name (Legal Business Name): MINDSHIFT COUNSELING GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 PLANTATION DR
SUMMERVILLE SC
29485-3423
US

IV. Provider business mailing address

507 FRONT ST # 2087
SUMMERVILLE SC
29486-7919
US

V. Phone/Fax

Practice location:
  • Phone: 585-953-3564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARIAH TAYLOR
Title or Position: LISW-CP
Credential:
Phone: 585-953-3564