Provider Demographics
NPI:1164656211
Name:PEACEFUL SPIRIT
Entity Type:Organization
Organization Name:PEACEFUL SPIRIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAHLKE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC, CAC III
Authorized Official - Phone:970-563-4555
Mailing Address - Street 1:296 MOUACHE ST.
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137
Mailing Address - Country:US
Mailing Address - Phone:970-563-4555
Mailing Address - Fax:
Practice Address - Street 1:296 MOUACHE
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137
Practice Address - Country:US
Practice Address - Phone:970-563-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN UTE COMMUNITY ACTION PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1106-00324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility