Provider Demographics
NPI:1265074777
Name:MOUNTAIN CREST COUNSELING, LLC
Entity type:Organization
Organization Name:MOUNTAIN CREST COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRUJILLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:505-263-4184
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:JEMEZ SPRINGS
Mailing Address - State:NM
Mailing Address - Zip Code:87025-0192
Mailing Address - Country:US
Mailing Address - Phone:505-263-4184
Mailing Address - Fax:
Practice Address - Street 1:16921 HIGHWAY 4
Practice Address - Street 2:
Practice Address - City:JEMEZ SPRINGS
Practice Address - State:NM
Practice Address - Zip Code:87025-9453
Practice Address - Country:US
Practice Address - Phone:505-263-4184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty