Healthcare Provider Details

I. General information

NPI: 1265449805
Provider Name (Legal Business Name): MELINDA ANN SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MELINDA SMITH MASON

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 VALLEY GROVE DR #D
LOLO MT
59847
US

IV. Provider business mailing address

9801 VALLEY GROVE DR #D
LOLO MT
59847
US

V. Phone/Fax

Practice location:
  • Phone: 406-273-4633
  • Fax: 406-273-4707
Mailing address:
  • Phone: 406-273-4633
  • Fax: 406-273-4707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number157
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6469
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1521
License Number StateWY
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-157
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: