Provider Demographics
NPI:1336788868
Name:SOUTH MOUNTAIN FAMILY PSYCHIATRY, LLC
Entity Type:Organization
Organization Name:SOUTH MOUNTAIN FAMILY PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:602-418-9105
Mailing Address - Street 1:11022 S 51ST ST STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-4308
Mailing Address - Country:US
Mailing Address - Phone:480-939-6137
Mailing Address - Fax:602-429-8445
Practice Address - Street 1:11022 S 51ST ST STE 250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-4308
Practice Address - Country:US
Practice Address - Phone:480-939-6137
Practice Address - Fax:602-429-8445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-01
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty