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General NPI Number Information
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NPI Number | 1215698907
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Entity Type | Organization
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Legal Business Name | GRANITE COUNSELING OF MONTANA, LLC
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Dates
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Enumeration Date | 01/04/2022
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Last Update Date | 01/04/2022
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Provider Practice Location Address
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Address Line | 32 CAMPUS DR
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City | MISSOULA
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State | MT
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Zip | 59812-0003
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Country | US
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Telephone | 406-360-3157
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Fax |
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Provider Business Mailing Address
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Address Line | 4010 HERITAGE WAY
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City | MISSOULA
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State | MT
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Zip | 59802-3050
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Country | US
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Telephone | 406-360-3157
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINICIAN
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Name | SARA ANNE POLANCHEK
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Credential | LCSW
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Telephone | 406-360-3157
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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