Provider Demographics
NPI:1497529630
Name:MOUNTAINSIDE COUNSELING PLLC
Entity Type:Organization
Organization Name:MOUNTAINSIDE COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MCKENZIE
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:385-390-3579
Mailing Address - Street 1:240 N EAST PROMONTORY STE 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2950
Mailing Address - Country:US
Mailing Address - Phone:385-390-3579
Mailing Address - Fax:
Practice Address - Street 1:240 N EAST PROMONTORY STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2950
Practice Address - Country:US
Practice Address - Phone:385-390-3579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty