Provider Demographics
NPI:1467171744
Name:MELLOW MOUNTAIN COUNSELING PLLC
Entity Type:Organization
Organization Name:MELLOW MOUNTAIN COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUNNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-709-9447
Mailing Address - Street 1:824 MCCORMICK RD
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-5102
Mailing Address - Country:US
Mailing Address - Phone:208-248-0477
Mailing Address - Fax:
Practice Address - Street 1:824 MCCORMICK RD
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-5102
Practice Address - Country:US
Practice Address - Phone:208-248-0477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)