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General NPI Number Information
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NPI Number | 1710303573
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Entity Type | Organization
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Legal Business Name | INNER PEACE THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 03/17/2014
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Last Update Date | 02/02/2024
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Provider Practice Location Address
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Address Line | 22776 THREE NOTCH RD STE 210
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City | LEXINGTON PARK
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State | MD
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Zip | 20653-3370
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Country | US
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Telephone | 301-866-6333
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Fax | 240-718-1906
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Provider Business Mailing Address
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Address Line | PO BOX 1662
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City | LEXINGTON PARK
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State | MD
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Zip | 20653-1662
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Country | US
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Telephone | 240-718-8460
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Fax | 240-718-1906
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Authorized Official
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Title or Position | OWNER
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Name | JACQUELINE DALE GRANTLAND
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Credential | DR.
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Telephone | 301-866-6333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LC4189
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License Number State | MD
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