Provider Demographics
NPI:1093131286
Name:GROSSKOP, LEVI (LAC)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:
Last Name:GROSSKOP
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:LEVI
Other - Middle Name:BENJAMIN
Other - Last Name:GROSSKOP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:MT
Mailing Address - Zip Code:59037-0028
Mailing Address - Country:US
Mailing Address - Phone:406-839-8844
Mailing Address - Fax:
Practice Address - Street 1:117 NORTHERN AVE STE B
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:MT
Practice Address - Zip Code:59037-9101
Practice Address - Country:US
Practice Address - Phone:406-839-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLAC 1356101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)