Healthcare Provider Details

I. General information

NPI: 1477316347
Provider Name (Legal Business Name): BOZEMAN SUPPORTIVE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 REEVES RD STE C
BOZEMAN MT
59718-7701
US

IV. Provider business mailing address

PO BOX 69
BINGEN WA
98605-0069
US

V. Phone/Fax

Practice location:
  • Phone: 406-813-1621
  • Fax:
Mailing address:
  • Phone: 406-813-1621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. MOLLY JO BASTA
Title or Position: LCPC
Credential: LCPC
Phone: 406-813-1621