Provider Demographics
NPI:1043398571
Name:O LEARY BENNETT, EVELYN ANN (RN LCPC)
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:ANN
Last Name:O LEARY BENNETT
Suffix:
Gender:F
Credentials:RN LCPC
Other - Prefix:
Other - First Name:EVY
Other - Middle Name:
Other - Last Name:O LEARY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN LCPC
Mailing Address - Street 1:127 N HIGGINS AVE RM 206
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4457
Mailing Address - Country:US
Mailing Address - Phone:406-549-2625
Mailing Address - Fax:
Practice Address - Street 1:127 N HIGGINS AVE RM 206
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4457
Practice Address - Country:US
Practice Address - Phone:406-549-2625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT484LCPC101YP2500X
MT09268163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0253657Medicaid
MT13005657OtherMT ST FUND PAYEE
MT74903OtherBCBS
MT00080078Medicare ID - Type Unspecified