Basic Information
| Provider Information | |||||||||
| NPI: | 1982272043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SILVER MOUNTAIN PSYCHOTHERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3967 COUNTY ROAD 116 | ||||||||
| Address2: | |||||||||
| City: | HESPERUS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813269482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467728283 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2257 MAIN AVE STE D | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813014660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702391791 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2021 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | BRAUN | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 6467728283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SILVER MOUNTAIN PSYCHOTHERAPY, LLC | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.