Provider Demographics
NPI:1528169117
Name:FOUR CORNERS MENTAL HEALTH, LLC
Entity type:Organization
Organization Name:FOUR CORNERS MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAUNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-382-6690
Mailing Address - Street 1:2855 MAIN AVE
Mailing Address - Street 2:SUITE A105
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301
Mailing Address - Country:US
Mailing Address - Phone:970-382-6690
Mailing Address - Fax:970-382-0207
Practice Address - Street 1:2855 MAIN AVE
Practice Address - Street 2:SUITE A105
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301
Practice Address - Country:US
Practice Address - Phone:970-382-6690
Practice Address - Fax:970-382-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40471103TC2200X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC807372Medicare PIN