Healthcare Provider Details

I. General information

NPI: 1427604354
Provider Name (Legal Business Name): EASTERN FRONT COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN ST STE 10
CONRAD MT
59425-2532
US

IV. Provider business mailing address

600 S MAIN ST STE 10
CONRAD MT
59425-2532
US

V. Phone/Fax

Practice location:
  • Phone: 406-278-0440
  • Fax: 406-278-0330
Mailing address:
  • Phone: 406-278-0440
  • Fax: 406-278-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONYA CARPENTER
Title or Position: OWNER
Credential: SWLC LAC
Phone: 406-278-0440