Provider Demographics
NPI:1902225436
Name:STELLAR MENTAL HEALTH & MEDIATION, LLC
Entity Type:Organization
Organization Name:STELLAR MENTAL HEALTH & MEDIATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:LSCW
Authorized Official - Phone:208-639-1514
Mailing Address - Street 1:923 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4731
Mailing Address - Country:US
Mailing Address - Phone:208-639-1514
Mailing Address - Fax:208-639-2301
Practice Address - Street 1:923 16TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4731
Practice Address - Country:US
Practice Address - Phone:208-639-1514
Practice Address - Fax:208-639-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)