Provider Demographics
NPI:1417493883
Name:ROCKY MOUNTAIN PSYCHOTHERAPY & NEUROFEEDBACK
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN PSYCHOTHERAPY & NEUROFEEDBACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-396-3500
Mailing Address - Street 1:2601 S 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-1143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 S 3RD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-1143
Practice Address - Country:US
Practice Address - Phone:406-396-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-6561041C0700X
MTBBH-LCSW-LIC-202571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT12167320OtherCAQH
MT0000071125OtherBLUE CROSS BLUE SHIELD
MT3323973OtherPACIFIC SOURCE
MT0503711Medicaid
MT3323973OtherPACIFIC SOURCE