Provider Demographics
NPI:1487681755
Name:HARTMAN, WALLACE D JR (MS LCPC)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:D
Last Name:HARTMAN
Suffix:JR
Gender:M
Credentials:MS LCPC
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 10714
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-3714
Mailing Address - Country:US
Mailing Address - Phone:406-257-5838
Mailing Address - Fax:
Practice Address - Street 1:307 1ST AVE E
Practice Address - Street 2:SUITE 20A
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4978
Practice Address - Country:US
Practice Address - Phone:406-257-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC 1073101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0256633Medicaid
MT74252-0OtherBLUE CROSS OF MONTANA