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General NPI Number Information
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NPI Number | 1720404841
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Entity Type | Organization
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Legal Business Name | MOUNTAIN PSYCHIATRIC, LLC
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Dates
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Enumeration Date | 03/13/2014
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Last Update Date | 03/19/2014
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Provider Practice Location Address
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Address Line | 5115 BERNARD DR SUITE 105
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City | ROANOKE
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State | VA
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Zip | 24018-4357
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Country | US
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Telephone | 540-728-1570
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Fax |
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Provider Business Mailing Address
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Address Line | 5115 BERNARD DR SUITE 105
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City | ROANOKE
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State | VA
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Zip | 24018-4357
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Country | US
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Telephone | 540-728-1570
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING
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Name | MS. JENNIFER COLORADO
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Credential |
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Telephone | 832-494-6448
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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