Healthcare Provider Details

I. General information

NPI: 1033879192
Provider Name (Legal Business Name): ANNE CHRISTINE WYSOSKI MS, PCLC, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E MAIN ST STE 319
BOZEMAN MT
59715-4721
US

IV. Provider business mailing address

652 SPRINGHILL LN
BOZEMAN MT
59715-9321
US

V. Phone/Fax

Practice location:
  • Phone: 406-624-9131
  • Fax:
Mailing address:
  • Phone: 406-624-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-PCLC-LIC-43491
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-50451
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: