Basic Information
| Provider Information | |||||||||
| NPI: | 1003490988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN VISTA PSYCHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88 INVERNESS CIR E UNIT E103 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801125511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205839332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7325 S PIERCE ST # 203E-103 | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801284553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205839332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2021 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCCONNELL | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7205839332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 9000166965 | 05 | CO | MEDICAID |