=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801062096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALLIE BORNSTEIN BANZIGER PHD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2008
-----------------------------------------------------
Last Update Date | 10/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 BANK ST SUITE 310
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-549-7325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 935 HIGHLAND BLVD SUITE 4400
-----------------------------------------------------
City | BOZEMAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59715-6904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-219-3311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HALLIE ALYSSA BORNSTEIN BANZIGER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 406-219-3311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 366
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------