Healthcare Provider Details

I. General information

NPI: 1104064195
Provider Name (Legal Business Name): JANIS M PEDRO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 5TH AVE
LAUREL MT
59044-2913
US

IV. Provider business mailing address

#20 5TH AVENUE
LAUREL MT
59044-9299
US

V. Phone/Fax

Practice location:
  • Phone: 307-272-5881
  • Fax:
Mailing address:
  • Phone: 307-272-5881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number935
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-524
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: