Healthcare Provider Details

I. General information

NPI: 1003677683
Provider Name (Legal Business Name): SHAPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N HIGGINS AVE STE 204
MISSOULA MT
59802-4401
US

IV. Provider business mailing address

111 N HIGGINS AVE STE 204
MISSOULA MT
59802-4401
US

V. Phone/Fax

Practice location:
  • Phone: 406-220-5581
  • Fax:
Mailing address:
  • Phone: 406-220-5581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ARI SILVERMAN
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 406-220-5581