Healthcare Provider Details

I. General information

NPI: 1053238584
Provider Name (Legal Business Name): MOUNTAIN STATES PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 PEARL ST STE 300
BOULDER CO
80302-4673
US

IV. Provider business mailing address

4845 PEARL EAST CIR SUITE 118 PMB 934664
BOULDER CO
80301-6112
US

V. Phone/Fax

Practice location:
  • Phone: 970-602-4222
  • Fax: 720-684-0656
Mailing address:
  • Phone: 970-602-4222
  • Fax: 720-684-0656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHANISE CHRISTOPHER
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 970-602-4222