Provider Demographics
NPI:1609571173
Name:GRAND CANYON PSYCHIATRIC SERVICES PLLC
Entity Type:Organization
Organization Name:GRAND CANYON PSYCHIATRIC SERVICES PLLC
Other - Org Name:GRAND CANYON PSYCHIATRIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:NJOGU
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:316-371-9196
Mailing Address - Street 1:28581 N CLOVER CIR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5869
Mailing Address - Country:US
Mailing Address - Phone:316-371-9196
Mailing Address - Fax:
Practice Address - Street 1:28581 N CLOVER CIR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5869
Practice Address - Country:US
Practice Address - Phone:316-371-9196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty