Provider Demographics
NPI:1164937793
Name:QUACKENBUSH, SETH MARWA (LCSW)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:MARWA
Last Name:QUACKENBUSH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:ST. IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865
Mailing Address - Country:US
Mailing Address - Phone:406-745-3681
Mailing Address - Fax:
Practice Address - Street 1:109 1ST AVENUE
Practice Address - Street 2:
Practice Address - City:ST. IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865
Practice Address - Country:US
Practice Address - Phone:406-745-3681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-260071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical