=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922881663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELDER TREE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2023
-----------------------------------------------------
Last Update Date | 08/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 BROADWAY ST
-----------------------------------------------------
City | TOWNSEND
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59644-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-813-1559
-----------------------------------------------------
Fax | 406-302-0901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 S OAK ST
-----------------------------------------------------
City | TOWNSEND
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59644-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-813-1559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | AUBREY HANCOCK
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 406-813-1559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------