Provider Demographics
NPI:1003401910
Name:BITTERROOT FAMILY THERAPY INC.
Entity Type:Organization
Organization Name:BITTERROOT FAMILY THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARIMER BURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:707-962-3161
Mailing Address - Street 1:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-0653
Mailing Address - Country:US
Mailing Address - Phone:707-962-3161
Mailing Address - Fax:707-937-1876
Practice Address - Street 1:347 CYPRESS ST STE A
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5458
Practice Address - Country:US
Practice Address - Phone:707-962-3161
Practice Address - Fax:707-937-1876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952445454Medicaid