Healthcare Provider Details

I. General information

NPI: 1013422781
Provider Name (Legal Business Name): ANNEMARIE DUBOIS, LCSW, L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 STONERIDGE DR STE D
BOZEMAN MT
59718-7079
US

IV. Provider business mailing address

PO BOX 4193
BOZEMAN MT
59772-4193
US

V. Phone/Fax

Practice location:
  • Phone: 802-999-4559
  • Fax:
Mailing address:
  • Phone: 802-999-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberSWP-LCSW-LIC-4591
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberSWP-LCSW-LIC-4591
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberSWP-LCSW-LIC-4591
License Number StateMT

VIII. Authorized Official

Name: ANNEMARIE DUBOIS
Title or Position: THERAPIST
Credential: LCSW
Phone: 802-999-4559