Provider Demographics
NPI:1033693171
Name:MOUNTAIN VISTA PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN VISTA PSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
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 1:1520 FAWNWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9550
Mailing Address - Country:US
Mailing Address - Phone:720-934-5507
Mailing Address - Fax:
Practice Address - Street 1:88 INVERNESS CIR E STE 103
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-5304
Practice Address - Country:US
Practice Address - Phone:720-583-9332
Practice Address - Fax:720-213-4084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-24
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========Medicaid