Healthcare Provider Details

I. General information

NPI: 1821515925
Provider Name (Legal Business Name): SHERI LEE MORTENSEN-BLACKWOOD LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHERI BLACKWOOD LCPC

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 FAIRWAY DRIVE
BOZEMAN MT
59715
US

IV. Provider business mailing address

2505 FAIRWAY DR
BOZEMAN MT
59715-5862
US

V. Phone/Fax

Practice location:
  • Phone: 406-579-1531
  • Fax:
Mailing address:
  • Phone: 406-579-1531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-1332
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number73489
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: