Healthcare Provider Details

I. General information

NPI: 1801456876
Provider Name (Legal Business Name): REBECCA ANNIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E PARK AVE STE 211
ANACONDA MT
59711-2351
US

IV. Provider business mailing address

1321 WYOMING ST
MISSOULA MT
59801-1725
US

V. Phone/Fax

Practice location:
  • Phone: 406-563-3413
  • Fax: 406-563-7463
Mailing address:
  • Phone: 406-532-8400
  • Fax: 406-224-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-38121
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: