Provider Demographics
NPI:1962045328
Name:MOUNTAIN MIND, LLC
Entity Type:Organization
Organization Name:MOUNTAIN MIND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:YORK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:720-788-6068
Mailing Address - Street 1:129 W SACKETT AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2056
Mailing Address - Country:US
Mailing Address - Phone:719-207-4455
Mailing Address - Fax:719-207-4464
Practice Address - Street 1:2535 17TH ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-6416
Practice Address - Country:US
Practice Address - Phone:720-788-6068
Practice Address - Fax:719-207-4464
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN MIND, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1952823403Medicaid