=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043085095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN WELLNESS THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2023
-----------------------------------------------------
Last Update Date | 05/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 W PARK ST
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59047-2530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-220-7893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 W PARK ST
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59047-2530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-220-7893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANNA DEWEES
-----------------------------------------------------
Credential | LCPC, LAC
-----------------------------------------------------
Telephone | 406-220-7893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------