Healthcare Provider Details

I. General information

NPI: 1467110726
Provider Name (Legal Business Name): MOUA KO MOUA LAC, SWLC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 CONNERY WAY
MISSOULA MT
59808-1325
US

IV. Provider business mailing address

329 CHIEF LOOKING GLASS RD
FLORENCE MT
59833-6638
US

V. Phone/Fax

Practice location:
  • Phone: 406-203-9948
  • Fax: 406-203-9949
Mailing address:
  • Phone: 406-529-7997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-64332
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-71084
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: