Provider Demographics
NPI:1083240386
Name:PEACE OF MIND FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:PEACE OF MIND FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:541-222-9231
Mailing Address - Street 1:151 SW SHEVLIN HIXON DR STE 201
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3233
Mailing Address - Country:US
Mailing Address - Phone:458-202-9231
Mailing Address - Fax:541-797-6113
Practice Address - Street 1:151 SW SHEVLIN HIXON DR STE 201
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3233
Practice Address - Country:US
Practice Address - Phone:458-202-9231
Practice Address - Fax:541-797-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1194057661Medicaid