Healthcare Provider Details

I. General information

NPI: 1861849366
Provider Name (Legal Business Name): RONALD HENDRICKSON LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W MERCURY ST
BUTTE MT
59701-1510
US

IV. Provider business mailing address

109 BELL ST
BUTTE MT
59701-8607
US

V. Phone/Fax

Practice location:
  • Phone: 406-299-3448
  • Fax: 406-299-3450
Mailing address:
  • Phone: 406-490-6656
  • Fax: 406-299-3450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAC-LAC-LIC-1421
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: