1386262046 NPI number — DR. SHANNON ST. ONGE SCALLY DNP

Table of content: DR. SHANNON ST. ONGE SCALLY DNP (NPI 1386262046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386262046 NPI number — DR. SHANNON ST. ONGE SCALLY DNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCALLY
Provider First Name:
SHANNON
Provider Middle Name:
ST. ONGE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386262046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2431 RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59804-1239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-360-5093
Provider Business Mailing Address Fax Number:
406-720-7944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SCALLY PSYCHIATRIC MENTAL HEALTH
Provider Second Line Business Practice Location Address:
2431 RIVER ROAD
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59804-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-360-5093
Provider Business Practice Location Address Fax Number:
406-720-7944
Provider Enumeration Date:
07/09/2020

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: 363LP0808X , with the licence number:  195702 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , with the licence number: 27210 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: $$$$$$$$$ . This is a "NA" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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