MEDICARE: SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528108073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE

Provider Business Mailing Address
First Line	:	PO BOX 21069
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29221-1069
Country	:	US
Telephone Number	:	803-896-4751
Fax Number	:	803-896-8473

Provider Business Practice Location Address
First Line	:	100 EXECUTIVE CENTER DR
Second Line	:	SANTEE BUILDING SUITE210
City	:	COLUMBIA
State	:	SC
Zip	:	29210-8407
Country	:	US
Telephone Number	:	803-896-4751
Fax Number	:	803-896-8473

Authorized Official
Title or Position	:	MEDICAID PROJECT ADMINISTRATOR
Name	:	MS. MIA L RICHARDSON
Credential	:
Telephone Number	:	803-896-4751

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	08/22/2020

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Directions to “SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE ” Practice Location

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