Provider Demographics
NPI:1073560793
Name:INNER JOURNEY PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:INNER JOURNEY PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:INNER JOURNEY PSYCHOLOGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER / PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NECOE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OTTO-PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-971-5578
Mailing Address - Street 1:2200 E RIVER RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6579
Mailing Address - Country:US
Mailing Address - Phone:520-971-5578
Mailing Address - Fax:520-577-3516
Practice Address - Street 1:2200 E RIVER RD
Practice Address - Street 2:SUITE 121
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6579
Practice Address - Country:US
Practice Address - Phone:520-971-5578
Practice Address - Fax:520-577-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34348103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ110377Medicare PIN