Healthcare Provider Details

I. General information

NPI: 1609467364
Provider Name (Legal Business Name): ADVANCED TELEPSYCHIATRY OF ALASKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11470 BUSINESS BLVD
EAGLE RIVER AK
99577-7780
US

IV. Provider business mailing address

PO BOX 770824
EAGLE RIVER AK
99577-0824
US

V. Phone/Fax

Practice location:
  • Phone: 907-406-6690
  • Fax:
Mailing address:
  • Phone: 907-406-6690
  • Fax: 907-726-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AMBER VIRDEN
Title or Position: APRN
Credential: DNP, ANP-BC, PMHNP
Phone: 907-406-6690