=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558869123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NESTING COMMUNITIES COUNSELING AND ART THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2018
-----------------------------------------------------
Last Update Date | 01/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 334 E BROADWAY ST
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-4618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-302-7725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 BYRON ST UNIT 203
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-2273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-302-7725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | JULIENNE N REID STICKNEY
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 913-302-7725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 22757
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------