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General NPI Number Information
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NPI Number | 1265223382
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Entity Type | Individual
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Provider Name | CHASE GANNON
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Gender | Male
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Dates
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Enumeration Date | 05/16/2025
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Last Update Date | 05/16/2025
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Provider Practice Location Address
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Address Line | 202 BROOKS ST STE 300
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City | MISSOULA
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State | MT
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Zip | 59801-4019
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Country | US
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Telephone | 406-926-1453
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Fax |
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Provider Business Mailing Address
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Address Line | 519 FLOOD RD
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City | GREAT FALLS
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State | MT
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Zip | 59404-6442
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Country | US
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Telephone | 406-868-7502
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | BBH-LAC-LIC-79686
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License Number State | MT
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