Provider Demographics
NPI:1043728314
Name:KROGSTAD, AYME LYNNE (LCPC)
Entity Type:Individual
Prefix:
First Name:AYME
Middle Name:LYNNE
Last Name:KROGSTAD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 EDITH ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-3907
Mailing Address - Country:US
Mailing Address - Phone:406-788-3880
Mailing Address - Fax:
Practice Address - Street 1:2237 S 3RD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1334
Practice Address - Country:US
Practice Address - Phone:406-541-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-29160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1043728314Medicaid