Provider Demographics
NPI:1467710442
Name:DALLACQUA, TIMOTHY LESLIE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LESLIE
Last Name:DALLACQUA
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 1:600 CENTRAL AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-3179
Mailing Address - Country:US
Mailing Address - Phone:406-868-8017
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3179
Practice Address - Country:US
Practice Address - Phone:406-868-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical