Healthcare Provider Details

I. General information

NPI: 1992638589
Provider Name (Legal Business Name): PETER S AIMSBACK JR. ACLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 3RD AVE E
POLSON MT
59860-2113
US

IV. Provider business mailing address

15 3RD AVE E
POLSON MT
59860-2113
US

V. Phone/Fax

Practice location:
  • Phone: 406-319-2082
  • Fax:
Mailing address:
  • Phone: 406-319-2082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-ACLC-LIC-81221
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: