1629091152 NPI number — MRS. MARY BARRON WOLDSTAD M.A., L.C.P.C., C.M.

Table of content: MRS. MARY BARRON WOLDSTAD M.A., L.C.P.C., C.M. (NPI 1629091152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629091152 NPI number — MRS. MARY BARRON WOLDSTAD M.A., L.C.P.C., C.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLDSTAD
Provider First Name:
MARY
Provider Middle Name:
BARRON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., L.C.P.C., C.M.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STURHAN
Provider Other First Name:
MARY
Provider Other Middle Name:
BARRON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A., L.C.P.C., C.M.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629091152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 21
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALIER
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59486-0021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-338-3671
Provider Business Mailing Address Fax Number:
406-338-3671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
422 MONTANA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALIER
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-338-3671
Provider Business Practice Location Address Fax Number:
406-338-3671
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1156 LCPC , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 1156-LCPC , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: 17659 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000742990 . This is a "BLUE CROSS/SHIELD OF MONT" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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