Healthcare Provider Details

I. General information

NPI: 1144366246
Provider Name (Legal Business Name): DISTRICT II ALCOHOL AND DRUG PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S KENDRICK AVE
GLENDIVE MT
59330-1626
US

IV. Provider business mailing address

119 S KENDRICK AVE
GLENDIVE MT
59330-1626
US

V. Phone/Fax

Practice location:
  • Phone: 406-377-5942
  • Fax: 406-377-3050
Mailing address:
  • Phone: 406-377-5942
  • Fax: 406-377-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number211-07
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier320042
Identifier TypeMEDICAID
Identifier StateMT
Identifier Issuer
# 2
Identifier76361
Identifier TypeOTHER
Identifier StateMT
Identifier IssuerBCBS PROVIDEER NUMBER

VIII. Authorized Official

Name: JERRY D SCHLEPP
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A., LAC
Phone: 406-377-5942