Healthcare Provider Details

I. General information

NPI: 1922453018
Provider Name (Legal Business Name): MISSION VALLEY SPEECH THERAPY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32441 MISSION CREEK RD
SAINT IGNATIUS MT
59865-9791
US

IV. Provider business mailing address

32441 MISSION CREEK RD
SAINT IGNATIUS MT
59865-9791
US

V. Phone/Fax

Practice location:
  • Phone: 406-370-5776
  • Fax: 406-745-4112
Mailing address:
  • Phone: 406-370-5776
  • Fax: 406-745-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number812
License Number StateMT

VIII. Authorized Official

Name: MRS. MARY HARNEY CALLAHAN
Title or Position: PRESIDENT
Credential: MS, CCC-SLP
Phone: 406-370-5776