MEDICARE: KAELA IMM MSW, LCSW

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	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	42706	OTHER	MT	ST LICENSE

General Provider Information

NPI Number	:	1679169585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAELA IMM MSW, LCSW

Provider Business Mailing Address
First Line	:	PO BOX 2214
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59103-2214
Country	:	US
Telephone Number	:	406-272-2532
Fax Number	:

Provider Business Practice Location Address
First Line	:	944 AVENUE B
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59102-3346
Country	:	US
Telephone Number	:	406-272-2532
Fax Number	:

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

Provider Enumeration Date	:	12/15/2020
Last Update Date	:	12/15/2020

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