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General NPI Number Information
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NPI Number | 1619465788
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Entity Type | Organization
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Legal Business Name | MEDICINE LODGE COUNSELING PLLC
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Dates
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Enumeration Date | 04/24/2018
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 2809 GREAT NORTHERN LOOP STE 210-5
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City | MISSOULA
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State | MT
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Zip | 59808-1749
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Country | US
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Telephone | 406-360-8470
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Fax |
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Provider Business Mailing Address
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Address Line | 14098 JENNY ANN CT UNIT A
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City | MISSOULA
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State | MT
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Zip | 59808-5386
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Country | US
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Telephone | 406-360-8470
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Fax |
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Authorized Official
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Title or Position | CLINICAL MENTAL HEALTH COUNSELOR
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Name | PAMELA C WILSON
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Credential | LCPC LAC
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Telephone | 406-360-8470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4654
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License Number State | MT
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