Provider Demographics
NPI:1093162257
Name:CCCS SMART PROGRAM
Entity Type:Organization
Organization Name:CCCS SMART PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ADDICTION COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JENI
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-299-3448
Mailing Address - Street 1:630 W MERCURY ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1510
Mailing Address - Country:US
Mailing Address - Phone:406-299-3448
Mailing Address - Fax:406-299-3450
Practice Address - Street 1:630 W MERCURY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1510
Practice Address - Country:US
Practice Address - Phone:406-299-3448
Practice Address - Fax:406-299-3450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT=========1Medicaid