Healthcare Provider Details

I. General information

NPI: 1306731617
Provider Name (Legal Business Name): CRYSTAL STAR LYGHT ACLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 US HIGHWAY 2 W SIDE
KALISPELL MT
59901-6071
US

IV. Provider business mailing address

PO BOX 1269
LIBBY MT
59923-1269
US

V. Phone/Fax

Practice location:
  • Phone: 406-314-6565
  • Fax: 406-314-6566
Mailing address:
  • Phone: 406-300-8302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-ACLC-LIC-78912
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: