=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023647096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER PEACE OUTREACH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2020
-----------------------------------------------------
Last Update Date | 01/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3107 SAN MATEO BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-712-6447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 CLAREMONT AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-1513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | COURTNEY HARRING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-761-5956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------