Provider Demographics
NPI:1326117409
Name:MOUNTAIN STATE PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN STATE PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-788-1113
Mailing Address - Street 1:130 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-3520
Mailing Address - Country:US
Mailing Address - Phone:304-788-1113
Mailing Address - Fax:304-788-2777
Practice Address - Street 1:130 CENTER ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-3520
Practice Address - Country:US
Practice Address - Phone:304-788-1113
Practice Address - Fax:304-788-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006086Medicaid
WV3810006086Medicaid