Provider Demographics
NPI:1346934288
Name:PEER SUPPORT NC
Entity Type:Organization
Organization Name:PEER SUPPORT NC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEON
Authorized Official - Middle Name:DEVONTE
Authorized Official - Last Name:BREEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LSCWA
Authorized Official - Phone:704-386-8651
Mailing Address - Street 1:5502 MCCHESNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7188
Mailing Address - Country:US
Mailing Address - Phone:704-492-5509
Mailing Address - Fax:
Practice Address - Street 1:1712 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-7151
Practice Address - Country:US
Practice Address - Phone:704-492-1533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)