Healthcare Provider Details

I. General information

NPI: 1114293354
Provider Name (Legal Business Name): ALEMBIC PSYCHOTHERAPY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 W ALDER ST STE. 28
MISSOULA MT
59802-4026
US

IV. Provider business mailing address

3505 W FORK PETTY CREEK RD
ALBERTON MT
59820-9313
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-4791
  • Fax: 406-728-4791
Mailing address:
  • Phone: 406-728-4791
  • Fax: 406-728-4791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number162LCSW
License Number StateMT

VIII. Authorized Official

Name: MR. VICTOR STAMPLEY
Title or Position: PRESIDENT
Credential: LCSW
Phone: 406-728-4791