Healthcare Provider Details

I. General information

NPI: 1972326288
Provider Name (Legal Business Name): SERENITY MOUNTAIN THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2243 MAIN AVE
DURANGO CO
81301-4699
US

IV. Provider business mailing address

620 SIERRA DR
DURANGO CO
81301-8319
US

V. Phone/Fax

Practice location:
  • Phone: 720-383-4886
  • Fax:
Mailing address:
  • Phone: 720-480-0710
  • Fax:

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: HALEY WIEDENMAN
Title or Position: OWNER
Credential: LPC
Phone: 720-480-0710