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1600 North Ave W Ste 106 Missoula MT 59801-5500 | |
| (406) 544-7678 | |
| (406) 926-3117 |
| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1600 North Ave W Ste 106, Missoula, Montana |
| Authorized Official Name and Position | Kristina Marie Miner (SOLE MEMBER) |
| Authorized Official Contact | 4065447678 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1600 North Ave W Ste 106 Missoula MT 59801-5500 Ph: (406) 544-7678 | 1600 North Ave W Ste 106 Missoula MT 59801-5500 Ph: (406) 544-7678 |
| NPI Number | 1720539745 |
|---|---|
| Provider Enumeration Date | 10/14/2016 |
| Last Update Date | 01/21/2019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720539745 | NPI | - | NPPES |
| 1538473004 | Medicaid | MT |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | BBH-LCSW-LIC-999 (Montana) | Primary |
| 251S00000X | Community/behavioral Health | BBH-LAC-LIC-1354 (Montana) | Secondary |
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