Provider Demographics
NPI:1053466144
Name:SPAAN-RAYMOND, PENNI (LCPC)
Entity Type:Individual
Prefix:
First Name:PENNI
Middle Name:
Last Name:SPAAN-RAYMOND
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:PENNI
Other - Middle Name:
Other - Last Name:RAYMOND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:PO BOX 9243
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-9243
Mailing Address - Country:US
Mailing Address - Phone:406-728-0078
Mailing Address - Fax:406-728-0078
Practice Address - Street 1:415 N HIGGINS AVE
Practice Address - Street 2:STE #114
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4522
Practice Address - Country:US
Practice Address - Phone:406-728-0078
Practice Address - Fax:406-728-0078
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MTLCPC 1066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT740640OtherBLUE CROSS BLUE SHIELD
MT0255748Medicaid