Healthcare Provider Details

I. General information

NPI: 1396296034
Provider Name (Legal Business Name): SUNBURST COMMUNITY SERVICE ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 1ST AVE
SAINT IGNATIUS MT
59865-0703
US

IV. Provider business mailing address

PO BOX 703
SAINT IGNATIUS MT
59865-0703
US

V. Phone/Fax

Practice location:
  • Phone: 406-745-3681
  • Fax:
Mailing address:
  • Phone: 406-745-3681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMT

VIII. Authorized Official

Name: JULIE FLECK
Title or Position: DIRECTOR
Credential: LCSW
Phone: 406-745-3681