=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083470181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN QUINN PORCO MS, CDCES, NBC-HWC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2024
-----------------------------------------------------
Last Update Date | 02/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 N PLATT AVE
-----------------------------------------------------
City | RED LODGE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59068-9184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-210-1143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1176
-----------------------------------------------------
City | RED LODGE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59068-1176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-210-1143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number | 972730872
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------