Provider Demographics
NPI:1083936033
Name:MOUNTAIN STATES HEALTH ALLIANCE OUT-PATIENT BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE OUT-PATIENT BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AVP BEHAVIORAL HEALTH AND REHAB SER
Authorized Official - Prefix:
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-952-1701
Mailing Address - Street 1:1021 W OAKLAND AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2191
Mailing Address - Country:US
Mailing Address - Phone:423-952-3104
Mailing Address - Fax:423-952-3109
Practice Address - Street 1:2012 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4645
Practice Address - Country:US
Practice Address - Phone:423-857-5566
Practice Address - Fax:423-857-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty