1417493883 NPI number — ROCKY MOUNTAIN PSYCHOTHERAPY & NEUROFEEDBACK

Table of content: (NPI 1417493883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417493883 NPI number — ROCKY MOUNTAIN PSYCHOTHERAPY & NEUROFEEDBACK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKY MOUNTAIN PSYCHOTHERAPY & NEUROFEEDBACK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1417493883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2601 S 3RD ST W
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:
59804-1143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 S 3RD ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59804-1143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-396-3500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
DOROTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
406-396-3500

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  BBH-LCSW-LIC-656 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: BBH-LCSW-LIC-20257 , 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: 12167320 . This is a "CAQH" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0000071125 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 3323973 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0503711 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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