Healthcare Provider Details

I. General information

NPI: 1639686462
Provider Name (Legal Business Name): LIVING WELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MAIN ST STE 203
HAMILTON MT
59840-2443
US

IV. Provider business mailing address

PO BOX 1707
HAMILTON MT
59840-1707
US

V. Phone/Fax

Practice location:
  • Phone: 406-363-2873
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7731-C
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-12274
License Number StateMT

VIII. Authorized Official

Name: KELLIE MILDENBERGER
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 406-363-2873