Healthcare Provider Details

I. General information

NPI: 1215698907
Provider Name (Legal Business Name): GRANITE COUNSELING OF MONTANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 CAMPUS DR
MISSOULA MT
59812-0003
US

IV. Provider business mailing address

4010 HERITAGE WAY
MISSOULA MT
59802-3050
US

V. Phone/Fax

Practice location:
  • Phone: 406-360-3157
  • Fax:
Mailing address:
  • Phone: 406-360-3157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SARA ANNE POLANCHEK
Title or Position: OWNER/CLINICIAN
Credential: LCSW
Phone: 406-360-3157