Healthcare Provider Details

I. General information

NPI: 1154671725
Provider Name (Legal Business Name): MITCHELL MORRISON VANCE B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 BARNES AVE
LA JUNTA CO
81050-2138
US

IV. Provider business mailing address

711 BARNES AVE
LA JUNTA CO
81050-2138
US

V. Phone/Fax

Practice location:
  • Phone: 719-384-5446
  • Fax: 719-384-5672
Mailing address:
  • Phone: 719-384-5446
  • Fax: 719-384-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: