Healthcare Provider Details

I. General information

NPI: 1366263071
Provider Name (Legal Business Name): BROOKLYN NICOLE ROBERTSON LCSW, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS BROOKLYN NICOLE AMBUEHL

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N CALIFORNIA ST
MISSOULA MT
59802-3913
US

IV. Provider business mailing address

1100 W KENT AVE UNIT 1246
MISSOULA MT
59806-7049
US

V. Phone/Fax

Practice location:
  • Phone: 406-868-4861
  • Fax:
Mailing address:
  • Phone: 406-868-4861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-70324
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-72921
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: