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NPI Code Detail

MEDICARE: MRS. JUANITA NELSON LAC

MEDICARE: MRS. JUANITA NELSON LAC
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) Counselor829MT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
176208OTHERMOCHIP
20000076391OTHERMTBLUE CROSS BLUE SHIELD
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1497886758
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JUANITA NELSON LAC
Provider Business Mailing Address
First Line : 1312 NORTH MERIDIAN
Second Line :
City : KALISPELL
State : MT
Zip : 59904-0115
Country : US
Telephone Number : 406-756-6453
Fax Number : 406-756-8546
Provider Business Practice Location Address
First Line : 1312 N MERIDIAN RD
Second Line :
City : KALISPELL
State : MT
Zip : 59901-3095
Country : US
Telephone Number : 406-756-6453
Fax Number : 406-756-8546
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/08/2007
Last Update Date : 07/08/2007

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