Provider Demographics
NPI:1881007573
Name:MINDFUL BEHAVIORAL INC
Entity Type:Organization
Organization Name:MINDFUL BEHAVIORAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOMOYATTA
Authorized Official - Middle Name:AKILA
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-697-0767
Mailing Address - Street 1:2712 MIDDLEBURG DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2415
Mailing Address - Country:US
Mailing Address - Phone:803-569-1789
Mailing Address - Fax:
Practice Address - Street 1:210 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-3310
Practice Address - Country:US
Practice Address - Phone:843-487-5004
Practice Address - Fax:877-343-3190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC188BHSMedicaid
SCF027Medicare UPIN