MEDICARE: DESERT SPRING BEHAVIORAL HEALTH, 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	251S00000X	Community/Behavioral Health Agency	6593775-4405	UT
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1962803270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT SPRING BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	PO BOX 876023
Second Line	:
City	:	WASILLA
State	:	AK
Zip	:	99687-6023
Country	:	US
Telephone Number	:	907-203-1590
Fax Number	:	435-674-9380

Provider Business Practice Location Address
First Line	:	290 N WILLOW ST
Second Line	:
City	:	WASILLA
State	:	AK
Zip	:	99654-7042
Country	:	US
Telephone Number	:	907-203-1590
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	LISA MARIE MRZENA
Credential	:	PMHNP-BC
Telephone Number	:	907-301-6668

Provider Enumeration Date	:	09/07/2014
Last Update Date	:	06/16/2021

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