Healthcare Provider Details

I. General information

NPI: 1922583293
Provider Name (Legal Business Name): CARLY KLEINERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

2677 PALMER ST STE 300
MISSOULA MT
59808-1700
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-9800
  • Fax:
Mailing address:
  • Phone: 406-329-1543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-16926
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: