Provider Demographics
NPI:1912734575
Name:PEACH MENTAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:PEACH MENTAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-883-7787
Mailing Address - Street 1:34 SPRING WAY
Mailing Address - Street 2:
Mailing Address - City:CAMDEN WYOMING
Mailing Address - State:DE
Mailing Address - Zip Code:19934-4224
Mailing Address - Country:US
Mailing Address - Phone:302-257-9420
Mailing Address - Fax:
Practice Address - Street 1:34 SPRING WAY
Practice Address - Street 2:
Practice Address - City:CAMDEN WYOMING
Practice Address - State:DE
Practice Address - Zip Code:19934-4224
Practice Address - Country:US
Practice Address - Phone:302-257-9420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-17
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE250695513Medicaid