MEDICARE: MAHALA BACH LPC, QMHP

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1740604099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAHALA BACH LPC, QMHP

Provider Business Mailing Address
First Line	:	1575 N LACROSSE ST
Second Line	:	SUITE H
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6976
Country	:	US
Telephone Number	:	605-431-4106
Fax Number	:

Provider Business Practice Location Address
First Line	:	1575 N LACROSSE ST
Second Line	:	SUITE H
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6976
Country	:	US
Telephone Number	:	605-431-4106
Fax Number	:

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

Provider Enumeration Date	:	02/06/2014
Last Update Date	:	04/13/2016

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