MEDICARE: MARILYN FENTON MONTVILLE

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	101YM0800X	Mental Health Counselor	237	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11661674	OTHER	WY	CAQH UNIVERSAL CREDENTIAL

General Provider Information

NPI Number	:	1376695023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN FENTON MONTVILLE

Provider Business Mailing Address
First Line	:	1514 SHEPARD PL
Second Line	:
City	:	CODY
State	:	WY
Zip	:	82414-4220
Country	:	US
Telephone Number	:	307-587-9596
Fax Number	:

Provider Business Practice Location Address
First Line	:	721 SHERIDAN AVE
Second Line	:	SUITE 260
City	:	CODY
State	:	WY
Zip	:	82414-3423
Country	:	US
Telephone Number	:	307-527-5312
Fax Number	:	307-578-2212

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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Directions to “ MARILYN FENTON MONTVILLE ” Practice Location

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