Provider Demographics
NPI:1497765150
Name:STATE OF MONTANA
Entity Type:Organization
Organization Name:STATE OF MONTANA
Other - Org Name:MONTANA CHEMICAL DEPENDENCY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FACILITY REIMBURSEMENT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALEASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-444-3416
Mailing Address - Street 1:111 N SANDERS ST DEPT 30
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4520
Mailing Address - Country:US
Mailing Address - Phone:406-444-3416
Mailing Address - Fax:406-444-3082
Practice Address - Street 1:525 E MERCURY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1911
Practice Address - Country:US
Practice Address - Phone:406-496-5407
Practice Address - Fax:406-496-5437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084N0400X, 2084P0800X, 2084P0802X
MT10324324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT57-0112Medicaid
MT57-0362Medicaid
MT57-0112Medicaid
MT57-0362Medicaid