=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811089774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. JEANETTE STANGL INC PC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 09/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 SOUTH ORANGE STREET SACAJAWEA OFFICES
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-542-8461
-----------------------------------------------------
Fax | 406-542-7449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 EAST KENT AVE
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-6021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-542-8461
-----------------------------------------------------
Fax | 406-542-7449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 684LAC
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 454LCSW
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------