Provider Demographics
NPI:1477743532
Name:GREATLAND MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:GREATLAND MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RONCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-632-7577
Mailing Address - Street 1:PO BOX 111810
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-1810
Mailing Address - Country:US
Mailing Address - Phone:907-929-4009
Mailing Address - Fax:907-929-4902
Practice Address - Street 1:1407 W 31ST AVE
Practice Address - Street 2:STE 201
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3678
Practice Address - Country:US
Practice Address - Phone:907-929-4009
Practice Address - Fax:907-929-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH3538Medicaid
AK160485Medicare Oscar/Certification
H92084Medicare UPIN