MEDICARE: MS. GRACIA L SCHALL MS LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	55 LCPC	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	075310	OTHER	MT	BLUE CROSS

General Provider Information

NPI Number	:	1710950571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GRACIA L SCHALL MS LCPC

Provider Business Mailing Address
First Line	:	1640 SOUTH AVE W
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-7804
Country	:	US
Telephone Number	:	406-721-1774
Fax Number	:	406-721-1774

Provider Business Practice Location Address
First Line	:	1640 SOUTH AVENUE WEST
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801
Country	:	US
Telephone Number	:	406-721-1774
Fax Number	:	406-721-1774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	07/09/2007

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