Provider Demographics
NPI:1376118661
Name:GAULT, AMY (MSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GAULT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-0446
Mailing Address - Country:US
Mailing Address - Phone:406-529-1104
Mailing Address - Fax:
Practice Address - Street 1:307 1ST AVE E STE 16
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4965
Practice Address - Country:US
Practice Address - Phone:406-529-1104
Practice Address - Fax:406-730-5971
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-389471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical