Provider Demographics
NPI:1053825505
Name:MOUNTAIN THERAPY COLLABORATIVE
Entity type:Organization
Organization Name:MOUNTAIN THERAPY COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PSYD
Authorized Official - Phone:415-806-0275
Mailing Address - Street 1:870 EMERALD BAY RD STE 303
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-9400
Mailing Address - Country:US
Mailing Address - Phone:415-806-0275
Mailing Address - Fax:530-600-0063
Practice Address - Street 1:870 EMERALD BAY RD STE 303
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-9400
Practice Address - Country:US
Practice Address - Phone:415-806-0275
Practice Address - Fax:530-600-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1598157117Medicaid
NC1619169653Medicaid