Provider Demographics
NPI:1730964750
Name:BESPOKE PSYCHIATRY CLT, PLLC
Entity type:Organization
Organization Name:BESPOKE PSYCHIATRY CLT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:MARQUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:980-429-4597
Mailing Address - Street 1:1905 J N PEASE PL STE 202
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4539
Mailing Address - Country:US
Mailing Address - Phone:980-429-4597
Mailing Address - Fax:
Practice Address - Street 1:1905 J N PEASE PL STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4539
Practice Address - Country:US
Practice Address - Phone:980-429-4597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health