Provider Demographics
NPI:1164941175
Name:BURGESS-CONWAY, MILA R
Entity Type:Individual
Prefix:MRS
First Name:MILA
Middle Name:R
Last Name:BURGESS-CONWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 COLUMBIA COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 PALMETTO PARK BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7872
Practice Address - Country:US
Practice Address - Phone:803-359-7206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6230101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1164941175Medicaid