Provider Demographics
NPI:1003490988
Name:MOUNTAIN VISTA PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN VISTA PSYCHOLOGY, PLLC
Other - Org Name:MOUNTAIN VISTA PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-583-9332
Mailing Address - Street 1:88 INVERNESS CIR E UNIT E103
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-5511
Mailing Address - Country:US
Mailing Address - Phone:720-583-9332
Mailing Address - Fax:
Practice Address - Street 1:7325 S PIERCE ST # 203E-103
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80128-4553
Practice Address - Country:US
Practice Address - Phone:720-583-9332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-07
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000166965Medicaid