Healthcare Provider Details

I. General information

NPI: 1619516903
Provider Name (Legal Business Name): SHINING VALLEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72949 RICE LN
ARLEE MT
59821-9348
US

IV. Provider business mailing address

PO BOX 33
ARLEE MT
59821-0033
US

V. Phone/Fax

Practice location:
  • Phone: 406-210-5136
  • Fax:
Mailing address:
  • Phone: 406-210-5136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHANLEY M SWANSON
Title or Position: LCSW
Credential:
Phone: 406-210-5136