Healthcare Provider Details

I. General information

NPI: 1497765150
Provider Name (Legal Business Name): STATE OF MONTANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E MERCURY ST
BUTTE MT
59701-1911
US

IV. Provider business mailing address

111 N SANDERS ST DEPT 30
HELENA MT
59601-4520
US

V. Phone/Fax

Practice location:
  • Phone: 406-496-5407
  • Fax: 406-496-5437
Mailing address:
  • Phone: 406-444-3416
  • Fax: 406-444-3082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number10324
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. ALEASHA MARTIN
Title or Position: FACILITY REIMBURSEMENT MANAGER
Credential:
Phone: 406-444-3416