Provider Demographics
NPI:1093851107
Name:BERUBE, VIRGINIA (LAC)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BERUBE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S KENDRICK AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1626
Mailing Address - Country:US
Mailing Address - Phone:406-377-5942
Mailing Address - Fax:406-377-3050
Practice Address - Street 1:119 S KENDRICK AVE
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1626
Practice Address - Country:US
Practice Address - Phone:406-377-5942
Practice Address - Fax:406-377-3050
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1077101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)