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General NPI Number Information
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NPI Number | 1891171435
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Entity Type | Organization
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Legal Business Name | ALIVE AND WELL
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Dates
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Enumeration Date | 08/05/2015
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Last Update Date | 08/05/2015
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Provider Practice Location Address
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Address Line | 1611 N FORK RD
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City | COLUMBIA FALLS
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State | MT
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Zip | 59912-9410
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Country | US
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Telephone | 406-892-8830
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Fax |
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Provider Business Mailing Address
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Address Line | 1611 N FORK RD
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City | COLUMBIA FALLS
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State | MT
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Zip | 59912-9410
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Country | US
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Telephone | 406-892-8830
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MICHAEL STAMBORSKI
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Credential | LCPC, LAC
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Telephone | 406-892-8830
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 1103
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 1183
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License Number State | MT
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 1103
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License Number State | MT
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