Provider Demographics
NPI:1578341681
Name:MARIPOSA MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:MARIPOSA MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:BODNER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:617-312-7737
Mailing Address - Street 1:3465 N PINES WAY STE 104
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-9129
Mailing Address - Country:US
Mailing Address - Phone:617-312-7737
Mailing Address - Fax:
Practice Address - Street 1:580 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:617-312-7737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health