MEDICARE: SARA J SMALL ACLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	BBH-ACLC-LIC-65856	MT

General Provider Information

NPI Number	:	1235907221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA J SMALL ACLC

Provider Business Mailing Address
First Line	:	TWO RIVERS WELLNESS
Second Line	:	2911 WILSON STREET
City	:	MILES CITY
State	:	MT
Zip	:	59301
Country	:	US
Telephone Number	:	406-234-2929
Fax Number	:

Provider Business Practice Location Address
First Line	:	2911 WILSON ST
Second Line	:
City	:	MILES CITY
State	:	MT
Zip	:	59301-5722
Country	:	US
Telephone Number	:	406-234-2929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2023
Last Update Date	:	12/19/2023

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