Provider Demographics
NPI:1376184168
Name:PEAK WELLNESS PSYCHIATRY, A PROFESSIONAL NURSING CORPORATION
Entity Type:Organization
Organization Name:PEAK WELLNESS PSYCHIATRY, A PROFESSIONAL NURSING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:THEBO
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:888-909-8676
Mailing Address - Street 1:440 N BARRANCA AVE # 6619
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1722
Mailing Address - Country:US
Mailing Address - Phone:888-909-8676
Mailing Address - Fax:855-940-1848
Practice Address - Street 1:8880 RIO SAN DIEGO DR STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1642
Practice Address - Country:US
Practice Address - Phone:888-909-8676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-02
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty