Healthcare Provider Details

I. General information

NPI: 1386952190
Provider Name (Legal Business Name): GEORGIA LEE MATT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 HOSPITAL CIRCLE
BROWNING MT
59417
US

IV. Provider business mailing address

PO BOX 760
BROWNING MT
59417-0760
US

V. Phone/Fax

Practice location:
  • Phone: 406-338-6425
  • Fax: 406-338-6294
Mailing address:
  • Phone: 406-338-6425
  • Fax: 406-338-6294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1593
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 60088363
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: