Healthcare Provider Details

I. General information

NPI: 1982979126
Provider Name (Legal Business Name): MRS. BONNIE LEE MICKELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 NUCLEUS AVE.
COLUMBIA FALLS MT
59912
US

IV. Provider business mailing address

597 LEGACY LN
COLUMBIA FALLS MT
59912
US

V. Phone/Fax

Practice location:
  • Phone: 406-892-5304
  • Fax: 406-892-4038
Mailing address:
  • Phone: 406-892-5304
  • Fax: 406-892-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number909
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: