Provider Demographics
NPI:1508380569
Name:WAVRICK, LOWELL OWEN (LAC)
Entity Type:Individual
Prefix:
First Name:LOWELL
Middle Name:OWEN
Last Name:WAVRICK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4998 SONOMA ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-8694
Mailing Address - Country:US
Mailing Address - Phone:406-945-1730
Mailing Address - Fax:
Practice Address - Street 1:4998 SONOMA ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-8694
Practice Address - Country:US
Practice Address - Phone:406-945-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-24926101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty