Healthcare Provider Details

I. General information

NPI: 1891200911
Provider Name (Legal Business Name): MONARCH PSYCHIATRY OF ALASKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W BENSON BLVD STE 306
ANCHORAGE AK
99503-3936
US

IV. Provider business mailing address

101 W BENSON BLVD STE 306
ANCHORAGE AK
99503-3936
US

V. Phone/Fax

Practice location:
  • Phone: 907-885-1089
  • Fax: 907-885-1059
Mailing address:
  • Phone: 907-885-1089
  • Fax: 907-885-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1062801
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number1062801
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1364
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number576
License Number StateAK
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4965
License Number StateAK

VIII. Authorized Official

Name: LUCINDA MILLER-MANGROBANG
Title or Position: MEMBER MANAGER
Credential:
Phone: 907-885-1089