Provider Demographics
NPI:1043636046
Name:PEE DEE MENTAL HEALTH
Entity Type:Organization
Organization Name:PEE DEE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-629-2483
Mailing Address - Street 1:4 JESSAMINE ST
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:SC
Mailing Address - Zip Code:29510-4414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 N MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-7027
Practice Address - Country:US
Practice Address - Phone:843-394-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC3337Medicare UPIN