Healthcare Provider Details

I. General information

NPI: 1437488129
Provider Name (Legal Business Name): PEACHSTATE BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 DAVIS RD SUITE G
AUGUSTA GA
30907-2499
US

IV. Provider business mailing address

2421 CENTRAL AVE SUITE A
AUGUSTA GA
30904-6295
US

V. Phone/Fax

Practice location:
  • Phone: 706-726-4711
  • Fax:
Mailing address:
  • Phone: 706-726-0365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JULIE THOMAS
Title or Position: EXECUTIVE DIRECTOR
Credential: M.ED.
Phone: 706-726-4711