=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154979037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESTINATION ZEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2019
-----------------------------------------------------
Last Update Date | 09/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 EMERALD DR STE 1
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59105-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-534-6310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 EMERALD DR STE 1
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59105-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-534-6310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICIAN
-----------------------------------------------------
Name | MALISA FITZPATRICK
-----------------------------------------------------
Credential | LCPC, LAC
-----------------------------------------------------
Telephone | 406-390-3444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------