Healthcare Provider Details

I. General information

NPI: 1962970590
Provider Name (Legal Business Name): MICOLE FOUST LACOUNTE ACLC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 CONNERY WAY
MISSOULA MT
59808-1325
US

IV. Provider business mailing address

2620 CONNERY WAY
MISSOULA MT
59808-1325
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-ACLC-LIC-63769
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: