MEDICARE: CRYSTAL STAR LYGHT 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-78912	MT

General Provider Information

NPI Number	:	1306731617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL STAR LYGHT ACLC

Provider Business Mailing Address
First Line	:	PO BOX 1269
Second Line	:
City	:	LIBBY
State	:	MT
Zip	:	59923-1269
Country	:	US
Telephone Number	:	406-300-8302
Fax Number	:

Provider Business Practice Location Address
First Line	:	1203 US HIGHWAY 2 W SIDE
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-6071
Country	:	US
Telephone Number	:	406-314-6565
Fax Number	:	406-314-6566

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

Provider Enumeration Date	:	06/09/2025
Last Update Date	:	06/09/2025

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