Healthcare Provider Details

I. General information

NPI: 1669808887
Provider Name (Legal Business Name): THERESA A CONLEY LAC, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

3255 LT MOSS RD
MISSOULA MT
59804-7220
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-9800
  • Fax: 406-541-3032
Mailing address:
  • Phone: 406-532-8409
  • Fax: 406-543-9316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1405
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: