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General NPI Number Information
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NPI Number | 1114814209
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Entity Type | Organization
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Legal Business Name | MOUNTAIN MIND THERAPY LLC
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Dates
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Enumeration Date | 06/20/2025
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Last Update Date | 06/20/2025
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Provider Practice Location Address
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Address Line | 610 MAIN ST
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City | FRISCO
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State | CO
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Zip | 80443-5487
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Country | US
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Telephone | 970-306-6760
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6463
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City | BRECKENRIDGE
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State | CO
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Zip | 80424-6463
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Country | US
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Telephone | 207-807-9145
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Fax |
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Authorized Official
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Title or Position | LPCC
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Name | JACQUELINE BLACK
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Credential | MA, LPCC
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Telephone | 970-306-6760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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