Provider Demographics
NPI:1285962886
Name:MHA
Entity type:Organization
Organization Name:MHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARE PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLISSA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-735-9680
Mailing Address - Street 1:419 TORWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-714-0948
Mailing Address - Fax:
Practice Address - Street 1:200 CLAUDE BUNDRICK RD
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-9420
Practice Address - Country:US
Practice Address - Phone:803-786-5478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty