Healthcare Provider Details

I. General information

NPI: 1053962241
Provider Name (Legal Business Name): MOUNTAIN CARE NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 QUARRIER ST STE 310
CHARLESTON WV
25301-2338
US

IV. Provider business mailing address

1021 QUARRIER ST STE 310
CHARLESTON WV
25301-2338
US

V. Phone/Fax

Practice location:
  • Phone: 304-419-8890
  • Fax:
Mailing address:
  • Phone: 304-419-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL PRICE
Title or Position: OWNER
Credential: MSW, LICSW
Phone: 304-419-8890