Healthcare Provider Details

I. General information

NPI: 1164937793
Provider Name (Legal Business Name): SETH MARWA QUACKENBUSH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 1ST AVENUE
ST. IGNATIUS MT
59865
US

IV. Provider business mailing address

109 1ST AVE
ST. IGNATIUS MT
59865
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 Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-26007
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: