Healthcare Provider Details

I. General information

NPI: 1215781083
Provider Name (Legal Business Name): CARMELITA ANN MATT MSW, SWLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 FAIRVIEW AVE STE A
MISSOULA MT
59801-7873
US

IV. Provider business mailing address

PO BOX 1144
ST IGNATIUS MT
59865-1144
US

V. Phone/Fax

Practice location:
  • Phone: 406-214-3810
  • Fax: 406-720-7806
Mailing address:
  • Phone: 406-214-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-SWLC-LIC-70496
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: