Provider Demographics
NPI:1679195358
Name:MOUNTAIN LAKE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MOUNTAIN LAKE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:202-739-1784
Mailing Address - Street 1:6725 HONESTY DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-5516
Mailing Address - Country:US
Mailing Address - Phone:202-739-1784
Mailing Address - Fax:
Practice Address - Street 1:6725 HONESTY DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-5516
Practice Address - Country:US
Practice Address - Phone:202-739-1784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder