Provider Demographics
NPI:1063192078
Name:PEACH BLOSSOM THERAPY AND CONSULTATION SERVICES, PLLC
Entity type:Organization
Organization Name:PEACH BLOSSOM THERAPY AND CONSULTATION SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, THERAPIST AND CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:LUZ
Authorized Official - Last Name:PEACH
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW-CLINICAL
Authorized Official - Phone:906-233-7333
Mailing Address - Street 1:1100 LUDINGTON ST STE 301E
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-3549
Mailing Address - Country:US
Mailing Address - Phone:906-233-7333
Mailing Address - Fax:
Practice Address - Street 1:1100 LUDINGTON ST STE 301E
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-3549
Practice Address - Country:US
Practice Address - Phone:906-233-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty