=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649390881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRIENDS TO YOUTH INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 E BROADWAY ST
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-4929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-728-2662
-----------------------------------------------------
Fax | 406-728-2879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 E BROADWAY ST
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-4929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-728-2662
-----------------------------------------------------
Fax | 406-728-2879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMISTRATIVE ASSISTANT
-----------------------------------------------------
Name | LANA LOVELAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-728-2662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 621420
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------