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General NPI Number Information
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NPI Number | 1285962886
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Entity Type | Organization
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Legal Business Name | MHA
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Dates
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Enumeration Date | 11/20/2009
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Last Update Date | 11/20/2009
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Provider Practice Location Address
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Address Line | 200 CLAUDE BUNDRICK RD
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City | BLYTHEWOOD
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State | SC
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Zip | 29016-9420
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Country | US
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Telephone | 803-786-5478
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Fax |
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Provider Business Mailing Address
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Address Line | 419 TORWOOD DR
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City | COLUMBIA
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State | SC
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Zip | 29203
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Country | US
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Telephone | 803-714-0948
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Fax |
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Authorized Official
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Title or Position | CARE PROVIDER
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Name | MS. CARLISSA Y GOODWIN
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Credential |
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Telephone | 803-735-9680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 101YM0800X
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License Number State | SC
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