Provider Demographics
NPI:1659674661
Name:MAMIN, VICTORIA L (LMSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:MAMIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414
Mailing Address - Country:US
Mailing Address - Phone:843-816-3843
Mailing Address - Fax:
Practice Address - Street 1:2100 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5832
Practice Address - Country:US
Practice Address - Phone:843-312-5780
Practice Address - Fax:843-312-5780
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC167641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid