=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396513867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER PEACE WARRIORS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2023
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12101 BEAVER CREEK RD
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20124-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-354-5941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12101 BEAVER CREEK RD
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20124-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-354-5941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ASHLEY PATRICAN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 571-354-5941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------