Healthcare Provider Details

I. General information

NPI: 1508451790
Provider Name (Legal Business Name): MOUNTAIN VALLEY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W LOMBARD ST
BALTIMORE MD
21223-3134
US

IV. Provider business mailing address

PO BOX 6500
COLUMBIA MD
21045-6500
US

V. Phone/Fax

Practice location:
  • Phone: 507-405-4598
  • Fax:
Mailing address:
  • Phone: 507-405-4598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. BERGINA BRICKHOUSE ISBELL
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 507-405-4598