Provider Demographics
NPI:1659674661
Name:MAMIN, VICTORIA L (LCSW)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:MAMIN
Suffix:
Gender:
Credentials:LCSW
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 1:9020 OVERLOOK BLVD STE 130
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3259
Practice Address - Country:US
Practice Address - Phone:865-588-3173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC167641041C0700X
TN93561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid