Provider Demographics
NPI:1023511789
Name:THE PEACH PIT
Entity type:Organization
Organization Name:THE PEACH PIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:478-827-3224
Mailing Address - Street 1:PO BOX 891
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-0891
Mailing Address - Country:US
Mailing Address - Phone:478-827-3224
Mailing Address - Fax:478-827-3224
Practice Address - Street 1:1809 RIVER RD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-7029
Practice Address - Country:US
Practice Address - Phone:478-827-3224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No251V00000XAgenciesVoluntary or CharitableGroup - Multi-Specialty