Provider Demographics
NPI:1518029735
Name:MCGLOIN, TOM (LICENSE ADDICTION CO)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:
Last Name:MCGLOIN
Suffix:
Gender:M
Credentials:LICENSE ADDICTION CO
Other - Prefix:MRS
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:PATE TERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSE ADDICTION CO
Mailing Address - Street 1:25 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2801
Mailing Address - Country:US
Mailing Address - Phone:406-497-5070
Mailing Address - Fax:406-782-5180
Practice Address - Street 1:25 W FRONT ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2801
Practice Address - Country:US
Practice Address - Phone:406-497-5070
Practice Address - Fax:406-782-5180
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT234 -07251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT00320047Medicaid
MT76708OtherPRIVATE INSURANCE PROVID