Provider Demographics
NPI:1437425782
Name:AITCH, DESIREE RENEE (CAC I)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:RENEE
Last Name:AITCH
Suffix:
Gender:F
Credentials:CAC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2410
Mailing Address - Country:US
Mailing Address - Phone:864-467-3736
Mailing Address - Fax:864-467-3757
Practice Address - Street 1:1400 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2410
Practice Address - Country:US
Practice Address - Phone:864-467-3736
Practice Address - Fax:864-467-3757
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1003012101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)