MEDICARE: MOUNTAIN PEAKS COUNSELING, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	986029	CO

General Provider Information

NPI Number	:	1881925048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN PEAKS COUNSELING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2011
Second Line	:
City	:	RIFLE
State	:	CO
Zip	:	81650-2011
Country	:	US
Telephone Number	:	970-987-9879
Fax Number	:	970-384-2938

Provider Business Practice Location Address
First Line	:	111 E 3RD ST
Second Line	:	SUITE 203
City	:	RIFLE
State	:	CO
Zip	:	81650-2346
Country	:	US
Telephone Number	:	970-987-9879
Fax Number	:	970-384-2938

Authorized Official
Title or Position	:	OWNER/REGISTERED AGENT
Name	:	ROLAND E. ROSS
Credential	:	LCSW
Telephone Number	:	970-987-9879

Provider Enumeration Date	:	01/27/2010
Last Update Date	:	07/26/2011

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