=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891200911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONARCH PSYCHIATRY OF ALASKA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2017
-----------------------------------------------------
Last Update Date | 01/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W BENSON BLVD STE 306
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99503-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-885-1089
-----------------------------------------------------
Fax | 907-885-1059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 W BENSON BLVD STE 306
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99503-3936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-885-1089
-----------------------------------------------------
Fax | 907-885-1059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER MANAGER
-----------------------------------------------------
Name | LUCINDA MILLER-MANGROBANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-885-1089
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 576
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 4965
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 1062801
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 1364
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 1062801
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------