=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487866091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LONNIE LEE GRIBNAU L.C.P.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 01/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 RIVER VISTA CT
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59870-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-777-2516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 RIVER VISTA CT
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59870-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-777-2516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 447
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------