=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568017275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALISADES COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2019
-----------------------------------------------------
Last Update Date | 08/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 W 22ND ST
-----------------------------------------------------
City | RED LODGE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-446-9817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1802
-----------------------------------------------------
City | RED LODGE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59068-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-446-9817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | JOHN MONROE
-----------------------------------------------------
Credential | LCPC, LMFT
-----------------------------------------------------
Telephone | 406-446-9817
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------