Healthcare Provider Details

I. General information

NPI: 1215875109
Provider Name (Legal Business Name): TIFFANY ANNE BLAKE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5617 CARDINALS WAY UNIT 1
BILLINGS MT
59101-6441
US

IV. Provider business mailing address

5617 CARDINALS WAY UNIT 1
BILLINGS MT
59101-6441
US

V. Phone/Fax

Practice location:
  • Phone: 765-278-2966
  • Fax:
Mailing address:
  • Phone: 765-278-2966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-88178
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: