Provider Demographics
NPI:1114293354
Name:ALEMBIC PSYCHOTHERAPY INCORPORATED
Entity Type:Organization
Organization Name:ALEMBIC PSYCHOTHERAPY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:STAMPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-728-4791
Mailing Address - Street 1:3505 W FORK PETTY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ALBERTON
Mailing Address - State:MT
Mailing Address - Zip Code:59820-9313
Mailing Address - Country:US
Mailing Address - Phone:406-728-4791
Mailing Address - Fax:406-728-4791
Practice Address - Street 1:725 W ALDER ST
Practice Address - Street 2:STE. 28
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4026
Practice Address - Country:US
Practice Address - Phone:406-728-4791
Practice Address - Fax:406-728-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT162LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty