Provider Demographics
NPI:1669190864
Name:INNER PEACE PSYCHIATRIC SERVICES, LLC
Entity type:Organization
Organization Name:INNER PEACE PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:BRIDGET
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:928-404-2213
Mailing Address - Street 1:211 MOSER AVE UNIT 103
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86429-5249
Mailing Address - Country:US
Mailing Address - Phone:928-419-1036
Mailing Address - Fax:928-404-2213
Practice Address - Street 1:211 MOSER AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86429-5249
Practice Address - Country:US
Practice Address - Phone:928-419-1036
Practice Address - Fax:928-404-2213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1386159440Medicaid