Provider Demographics
NPI:1467110726
Name:MOUA, MOUA KO (LAC, SWLC)
Entity Type:Individual
Prefix:
First Name:MOUA
Middle Name:KO
Last Name:MOUA
Suffix:
Gender:M
Credentials:LAC, SWLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 CHIEF LOOKING GLASS RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6638
Mailing Address - Country:US
Mailing Address - Phone:406-529-7997
Mailing Address - Fax:
Practice Address - Street 1:2620 CONNERY WAY
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1325
Practice Address - Country:US
Practice Address - Phone:406-203-9948
Practice Address - Fax:406-203-9949
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-50445104100000X, 1041C0700X
MTBBH-LAC-LIC-64332101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical