MEDICARE: BLUE MOUNTAIN NEUROPSYCHOLOGICAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY60040765	WA

General Provider Information

NPI Number	:	1083005979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE MOUNTAIN NEUROPSYCHOLOGICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	1624 W DEAN AVE
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99201-1825
Country	:	US
Telephone Number	:	509-939-0719
Fax Number	:	509-464-6463

Provider Business Practice Location Address
First Line	:	1624 W DEAN AVE
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99201-1825
Country	:	US
Telephone Number	:	509-939-0719
Fax Number	:	509-464-6463

Authorized Official
Title or Position	:	OWNER
Name	:	JAMESON LONTZ
Credential	:	PHD
Telephone Number	:	509-939-0719

Provider Enumeration Date	:	02/12/2015
Last Update Date	:	01/26/2016

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