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NPI Code Detail

MEDICARE: MOUA KO MOUA LAC, SWLC

MEDICARE: MOUA KO MOUA LAC, SWLC
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
1101YA0400XAddiction (Substance Use Disorder) CounselorBBH-LAC-LIC-64332MT
21041C0700XClinical Social WorkerBBH-LCSW-LIC-71084MT

General Provider Information

NPI Number : 1467110726
Entity Type Code : Individual
Provider Name (Legal Business Name) : MOUA KO MOUA LAC, SWLC
Provider Business Mailing Address
First Line : 329 CHIEF LOOKING GLASS RD
Second Line :
City : FLORENCE
State : MT
Zip : 59833-6638
Country : US
Telephone Number : 406-529-7997
Fax Number :
Provider Business Practice Location Address
First Line : 2620 CONNERY WAY
Second Line :
City : MISSOULA
State : MT
Zip : 59808-1325
Country : US
Telephone Number : 406-203-9948
Fax Number : 406-203-9949
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/03/2021
Last Update Date : 05/23/2024

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