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General NPI Number Information
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NPI Number | 1750712808
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Entity Type | Organization
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Legal Business Name | MISSOULA FAMILY THERAPY, LLC
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Dates
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Enumeration Date | 11/27/2013
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Last Update Date | 01/15/2014
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Provider Practice Location Address
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Address Line | 110 E BROADWAY ST STE 204
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City | MISSOULA
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State | MT
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Zip | 59802-4592
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Country | US
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Telephone | 406-370-4664
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Fax |
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Provider Business Mailing Address
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Address Line | 110 E BROADWAY ST STE 204
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City | MISSOULA
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State | MT
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Zip | 59802-4592
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Country | US
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Telephone | 406-370-4664
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Fax |
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Authorized Official
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Title or Position | LMFT, LCPC
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Name | MS. STACY JENNINGS
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Credential | M.S.
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Telephone | 406-370-4664
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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 | SWPLCPCLIC4670
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License Number State | MT
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