Provider Demographics
NPI:1962653063
Name:MOUNTAIN HOME PSYCHIATRIC MEDICINE, PA
Entity Type:Organization
Organization Name:MOUNTAIN HOME PSYCHIATRIC MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-424-4804
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0387
Mailing Address - Country:US
Mailing Address - Phone:870-424-4804
Mailing Address - Fax:870-424-8651
Practice Address - Street 1:204 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3654
Practice Address - Country:US
Practice Address - Phone:870-424-4804
Practice Address - Fax:870-424-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty