=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265094601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODHI TREE COUNSELING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2019
-----------------------------------------------------
Last Update Date | 04/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 LAKE ELMO DR
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59105-3051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-694-5000
-----------------------------------------------------
Fax | 406-245-1156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 JEMSTONE DR
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59101-6854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-694-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | NATHAN LEE CHURCH
-----------------------------------------------------
Credential | LCSW, LAC
-----------------------------------------------------
Telephone | 406-694-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------