Provider Demographics
NPI:1952444911
Name:MESA BEHAVIORAL MEDICINE CLINIC, P. C.
Entity Type:Organization
Organization Name:MESA BEHAVIORAL MEDICINE CLINIC, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:970-241-1983
Mailing Address - Street 1:1400 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-3004
Mailing Address - Country:US
Mailing Address - Phone:970-241-1983
Mailing Address - Fax:970-242-6135
Practice Address - Street 1:1400 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-3004
Practice Address - Country:US
Practice Address - Phone:970-241-1983
Practice Address - Fax:970-242-6135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28579174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC80061Medicare ID - Type UnspecifiedMEDICARE NUMBER