Healthcare Provider Details

I. General information

NPI: 1891460366
Provider Name (Legal Business Name): AMY FANTOZZI LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W 9TH ST STE 2
LIBBY MT
59923-1866
US

IV. Provider business mailing address

2538 SWEDE MOUNTAIN RD
LIBBY MT
59923-7669
US

V. Phone/Fax

Practice location:
  • Phone: 406-291-2655
  • Fax:
Mailing address:
  • Phone: 406-283-1350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberBBH-LCPC-57447
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: