1720539745 NPI number — VALEO BEHAVIORAL HEALTH, LLC

Table of content: (NPI 1720539745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720539745 NPI number — VALEO BEHAVIORAL HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALEO BEHAVIORAL HEALTH, LLC
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:
KRISTINA M MINER
Provider Other Organization Name Type Code:
3
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:
1720539745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 NORTH AVE W STE 106
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:
59801-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-544-7678
Provider Business Mailing Address Fax Number:
406-926-3117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 NORTH AVE W STE 106
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:
59801-5500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-544-7678
Provider Business Practice Location Address Fax Number:
406-926-3117
Provider Enumeration Date:
10/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MINER
Authorized Official First Name:
KRISTINA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
406-544-7678

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  BBH-LCSW-LIC-999 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X , with the licence number: BBH-LAC-LIC-1354 , 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: 1538473004 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".