=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265519458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOOTENAI COUNSELING & CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 MAIN AVE
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-293-4644
-----------------------------------------------------
Fax | 406-293-7644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 MAIN AVE
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-293-4644
-----------------------------------------------------
Fax | 406-293-7644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PYSCHOLOGIST OWNER
-----------------------------------------------------
Name | MR. C. PETER VOLKMANN
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 406-293-4644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 279
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------