Healthcare Provider Details

I. General information

NPI: 1790174084
Provider Name (Legal Business Name): PIONEER PEAK MENTAL HEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 E NEW FIELD DR
WASILLA AK
99654-1416
US

IV. Provider business mailing address

PO BOX 873103
WASILLA AK
99687-3103
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-6642
  • Fax:
Mailing address:
  • Phone: 907-373-6642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number814
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. STEVEN RASMUSSEN
Title or Position: MANAGER
Credential:
Phone: 907-775-9042