Healthcare Provider Details

I. General information

NPI: 1346934288
Provider Name (Legal Business Name): PEER SUPPORT NC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 S LAFAYETTE ST
SHELBY NC
28152-7151
US

IV. Provider business mailing address

5502 MCCHESNEY DR
CHARLOTTE NC
28269-7188
US

V. Phone/Fax

Practice location:
  • Phone: 704-492-1533
  • Fax:
Mailing address:
  • Phone: 704-492-5509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. KEON DEVONTE BREEDEN
Title or Position: DIRECTOR
Credential: LSCWA
Phone: 704-386-8651