Provider Demographics
NPI:1477316347
Name:BOZEMAN SUPPORTIVE COUNSELING
Entity Type:Organization
Organization Name:BOZEMAN SUPPORTIVE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCPC
Authorized Official - Prefix:MS
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BASTA
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:406-813-1621
Mailing Address - Street 1:4 RABEL LN UNIT 34
Mailing Address - Street 2:
Mailing Address - City:GALLATIN GATEWAY
Mailing Address - State:MT
Mailing Address - Zip Code:59730-7002
Mailing Address - Country:US
Mailing Address - Phone:406-813-1621
Mailing Address - Fax:
Practice Address - Street 1:4150 VALLEY COMMONS DR STE B
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6407
Practice Address - Country:US
Practice Address - Phone:406-813-1621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-02
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health