Healthcare Provider Details

I. General information

NPI: 1093423121
Provider Name (Legal Business Name): RAYLENE VASSAU LAC, PCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 WILSON ST
MILES CITY MT
59301-5722
US

IV. Provider business mailing address

2911 WILSON ST
MILES CITY MT
59301-5722
US

V. Phone/Fax

Practice location:
  • Phone: 406-234-2929
  • Fax:
Mailing address:
  • Phone: 406-234-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBHH-LAC-LIC-66030
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: