Provider Demographics
NPI:1205526308
Name:VISTAS PEDIATRIC AND FAMILY MENTAL WELLNESS
Entity type:Organization
Organization Name:VISTAS PEDIATRIC AND FAMILY MENTAL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CROWE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC MSN, RN
Authorized Official - Phone:303-945-9676
Mailing Address - Street 1:2038 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7946
Mailing Address - Country:US
Mailing Address - Phone:303-945-9676
Mailing Address - Fax:833-547-1923
Practice Address - Street 1:698 BRIGGS ST.
Practice Address - Street 2:SUITE 4
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516
Practice Address - Country:US
Practice Address - Phone:720-324-7158
Practice Address - Fax:833-547-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000222832Medicaid