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General NPI Number Information
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NPI Number | 1740496397
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Entity Type | Individual
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Provider Name | LISA MUSTARD LMFT-I
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Gender | Female
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2016 ASSEMBLY ST
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City | COLUMBIA
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State | SC
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Zip | 29201-2142
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Country | US
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Telephone | 803-665-6399
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Fax |
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Provider Business Mailing Address
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Address Line | 509 S BONHAM RD
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City | COLUMBIA
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State | SC
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Zip | 29205-4010
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Country | US
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Telephone | 803-665-6399
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4750
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License Number State | SC
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