Provider Demographics
NPI:1467038828
Name:FAITH & FLY PSYCHIATRIC PRACTICE, LLC
Entity Type:Organization
Organization Name:FAITH & FLY PSYCHIATRIC PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-801-0878
Mailing Address - Street 1:3326 JACKSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-6600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2424 INDIA HOOK RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2784
Practice Address - Country:US
Practice Address - Phone:803-801-0878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B919OtherPTAN
SCGP6088Medicaid