=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225528110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSOULA THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2018
-----------------------------------------------------
Last Update Date | 06/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3819 STEPHENS AVE STE 300
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-215-2225
-----------------------------------------------------
Fax | 406-215-2226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3819 STEPHENS AVE STE 300
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-8522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-215-2225
-----------------------------------------------------
Fax | 406-215-2226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MR. ANDREW S HILL
-----------------------------------------------------
Credential | LCSW, CBIS
-----------------------------------------------------
Telephone | 406-215-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------