Healthcare Provider Details

I. General information

NPI: 1740980291
Provider Name (Legal Business Name): WHITE BUFFALO HEALING LODGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W PARK ST # 211
BUTTE MT
59701-1714
US

IV. Provider business mailing address

22 W PARK ST
BUTTE MT
59701-1714
US

V. Phone/Fax

Practice location:
  • Phone: 406-221-7058
  • Fax:
Mailing address:
  • Phone: 406-221-7058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MANDI BOSTON
Title or Position: EXECUTIVE DIRECTOR
Credential: LAC
Phone: 406-221-7058