Provider Demographics
NPI:1972977015
Name:MOUNTAIN PASS COUNSELING, LLC
Entity type:Organization
Organization Name:MOUNTAIN PASS COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAST
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:262-617-6446
Mailing Address - Street 1:30 KINGFISHER LN
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7432
Mailing Address - Country:US
Mailing Address - Phone:262-617-6446
Mailing Address - Fax:
Practice Address - Street 1:11930 MENAUL BLVD NE
Practice Address - Street 2:STE 114-A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2478
Practice Address - Country:US
Practice Address - Phone:262-617-6446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-29
Last Update Date:2015-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0174601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43711500Medicaid