Provider Demographics
NPI:1336315787
Name:MOLES, MICHELLE RAE (BSW, LAC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RAE
Last Name:MOLES
Suffix:
Gender:F
Credentials:BSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 FORT MISSOULA
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7203
Mailing Address - Country:US
Mailing Address - Phone:406-721-2700
Mailing Address - Fax:406-829-9518
Practice Address - Street 1:33 FORT MISSOULA
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7203
Practice Address - Country:US
Practice Address - Phone:406-721-2700
Practice Address - Fax:406-829-9518
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1252 LAC101YA0400X
MTBBH-LCSW-LIC-161331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)