Healthcare Provider Details

I. General information

NPI: 1124728068
Provider Name (Legal Business Name): TIFFANY ANN LINDQUIST LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 US HIGHWAY 93 S STE D
KALISPELL MT
59901-5776
US

IV. Provider business mailing address

1104 7TH AVE W
KALISPELL MT
59901-5685
US

V. Phone/Fax

Practice location:
  • Phone: 406-314-6565
  • Fax: 406-314-6565
Mailing address:
  • Phone: 406-491-5830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-62550
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: