Provider Demographics
NPI:1346876729
Name:ALTA MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:ALTA MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FODOR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:617-959-3994
Mailing Address - Street 1:100 HIGHLAND AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2702
Mailing Address - Country:US
Mailing Address - Phone:617-959-3994
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2702
Practice Address - Country:US
Practice Address - Phone:617-959-3994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty