Organization
SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MIA L RICHARDSON (MEDICAID PROJECT ADMINISTRATOR)
(803) 896-4751
Entity
Organization
Contact information
Practice address
100 EXECUTIVE CENTER DR, SANTEE BUILDING SUITE210, COLUMBIA, SC 29210-8407
(803) 896-4751
(803) 896-8473
Mailing address
PO BOX 21069, COLUMBIA, SC 29221-1069
(803) 896-4751
(803) 896-8473
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
969MXH
—
SC
Enumeration date
02/07/2007
Last updated
08/22/2020
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