Healthcare Provider Details

I. General information

NPI: 1174328678
Provider Name (Legal Business Name): ELY REYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 HODGSON RD
COLUMBIA FALLS MT
59912-9063
US

IV. Provider business mailing address

PO BOX 2218
COLUMBIA FALLS MT
59912-2218
US

V. Phone/Fax

Practice location:
  • Phone: 406-897-2788
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-ACLC-LIC-72607
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: