Healthcare Provider Details

I. General information

NPI: 1720750102
Provider Name (Legal Business Name): ASHLEY SHOEMAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

1321 WYOMING ST
MISSOULA MT
59801-1725
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-9800
  • Fax:
Mailing address:
  • Phone: 406-532-8400
  • Fax: 406-224-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-49916
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: