MEDICARE: BLACK MOUNTAIN BEHAVIORAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103G00000X	Clinical Neuropsychologist
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist
3	103TA0700X	Adult Development & Aging Psychologist
4	103TB0200X	Cognitive & Behavioral Psychologist
5	103TC0700X	Clinical Psychologist
6	103TC2200X	Clinical Child & Adolescent Psychologist
7	103TF0000X	Family Psychologist
8	103TF0200X	Forensic Psychologist
9	103TH0004X	Health Psychologist
10	103TP2701X	Group Psychotherapy Psychologist
11	103TR0400X	Rehabilitation Psychologist
12	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
13	261QM0850X	Adult Mental Health Clinic/Center
14	261QM0855X	Adolescent and Children Mental Health Clinic/Center
15	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1639589930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK MOUNTAIN BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	33755 N SCOTTSDALE RD
Second Line	:	SUITE J-105
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85266-1567
Country	:	US
Telephone Number	:	480-595-1555
Fax Number	:	866-307-0007

Provider Business Practice Location Address
First Line	:	33755 N SCOTTSDALE RD
Second Line	:	SUITE J-105
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85266-1567
Country	:	US
Telephone Number	:	480-595-1555
Fax Number	:	866-307-0007

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. KONSTANTINOS DIMITRIOS THOMOPOULOS
Credential	:	PSYD
Telephone Number	:	480-595-1555

Provider Enumeration Date	:	05/08/2014
Last Update Date	:	05/08/2014

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