Provider Demographics
NPI:1477113637
Name:BLUE MOUNTAIN WELLNESS, PLLC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSTANTINE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:215-647-2175
Mailing Address - Street 1:517 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2415
Mailing Address - Country:US
Mailing Address - Phone:215-647-2175
Mailing Address - Fax:
Practice Address - Street 1:517 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2415
Practice Address - Country:US
Practice Address - Phone:215-647-2175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-19
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1194082347OtherINDIVIDUAL NPI
PA1037502590001Medicaid