Provider Demographics
NPI:1104694389
Name:PEACE PAVILION MENTAL HEALTHCARE AND COUNSELING SERVICES PLLC
Entity type:Organization
Organization Name:PEACE PAVILION MENTAL HEALTHCARE AND COUNSELING SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:BOLANLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AWOTIKU
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:630-504-8745
Mailing Address - Street 1:11747 GIOVANNI LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1536
Mailing Address - Country:US
Mailing Address - Phone:630-504-8745
Mailing Address - Fax:
Practice Address - Street 1:9950 WESTPARK DR STE 528
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-5274
Practice Address - Country:US
Practice Address - Phone:630-504-8745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty