Provider Demographics
NPI:1720396773
Name:SERENITY HOUSE PCH, INC.
Entity Type:Organization
Organization Name:SERENITY HOUSE PCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEIDRE
Authorized Official - Middle Name:COBB
Authorized Official - Last Name:TIFT
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, RNC
Authorized Official - Phone:912-977-4643
Mailing Address - Street 1:210 GARDEN CIR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4421
Mailing Address - Country:US
Mailing Address - Phone:912-977-4663
Mailing Address - Fax:912-369-6530
Practice Address - Street 1:210 GARDEN CIR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4421
Practice Address - Country:US
Practice Address - Phone:912-977-4663
Practice Address - Fax:912-369-6530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI080640101YA0400X
GAMSW002656106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA047158461AMedicaid