Provider Demographics
NPI:1285110957
Name:MOOKIES PLACE
Entity type:Organization
Organization Name:MOOKIES PLACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LETISHA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SMALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-285-8589
Mailing Address - Street 1:PO BOX 1244
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29721-1244
Mailing Address - Country:US
Mailing Address - Phone:803-285-8589
Mailing Address - Fax:704-919-5055
Practice Address - Street 1:501 W MEETING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2323
Practice Address - Country:US
Practice Address - Phone:803-285-8589
Practice Address - Fax:704-919-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 251300000X, 251B00000X, 251S00000X
SC261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8581Medicaid