Healthcare Provider Details

I. General information

NPI: 1083936033
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE OUT-PATIENT BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 BROOKSIDE DR
KINGSPORT TN
37660-4645
US

IV. Provider business mailing address

1021 W OAKLAND AVE SUITE 207
JOHNSON CITY TN
37604-2191
US

V. Phone/Fax

Practice location:
  • Phone: 423-857-5566
  • Fax: 423-857-5564
Mailing address:
  • Phone: 423-952-3104
  • Fax: 423-952-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: GRACIELA PEREIRA
Title or Position: AVP BEHAVIORAL HEALTH AND REHAB SER
Credential:
Phone: 423-952-1701