=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962789875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE GOODWIN CLAY LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2011
-----------------------------------------------------
Last Update Date | 07/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9023 GARNERS FERRY RD
-----------------------------------------------------
City | HOPKINS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29061-9540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-978-1848
-----------------------------------------------------
Fax | 803-978-1852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2712 MIDDLEBURG DR STE 207B
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29204-2445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-238-5063
-----------------------------------------------------
Fax | 803-419-7497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5337
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------