Healthcare Provider Details

I. General information

NPI: 1760966832
Provider Name (Legal Business Name): BONITA MOSES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

1305 WYOMING ST
MISSOULA MT
59801-1725
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-9770
  • Fax:
Mailing address:
  • Phone: 406-532-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number31639
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: