| South Carolina Department Of Juvenile Justice | |
|
100 Executive Center Dr Santee Building Suite210 Columbia SC 29210-8407 | |
| (803) 896-4751 | |
| (803) 896-8473 |
| Full Name | South Carolina Department Of Juvenile Justice |
|---|---|
| Speciality | Psychologist |
| Location | 100 Executive Center Dr, Columbia, South Carolina |
| Authorized Official Name and Position | Mia L Richardson (MEDICAID PROJECT ADMINISTRATOR) |
| Authorized Official Contact | 8038964751 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| South Carolina Department Of Juvenile Justice Po Box 21069 Columbia SC 29221-1069 Ph: (803) 896-4751 | South Carolina Department Of Juvenile Justice 100 Executive Center Dr Santee Building Suite210 Columbia SC 29210-8407 Ph: (803) 896-4751 |
| NPI Number | 1528108073 |
|---|---|
| Provider Enumeration Date | 02/07/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1528108073 | NPI | - | NPPES |
| 969MXH | Medicaid | SC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | (* (Not Available)) | Primary |
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