Provider Demographics
NPI:1518449222
Name:WALTENBAUGH, SHALOM FRANCHONT (LCSW, LAC)
Entity Type:Individual
Prefix:MR
First Name:SHALOM
Middle Name:FRANCHONT
Last Name:WALTENBAUGH
Suffix:
Gender:M
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 DOROTHY LN
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-2506
Mailing Address - Country:US
Mailing Address - Phone:406-208-4289
Mailing Address - Fax:
Practice Address - Street 1:527 LAKE ELMO DR
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-3051
Practice Address - Country:US
Practice Address - Phone:406-208-4289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-3393101YA0400X
MTBBH-LCSW-LIC-439951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1518449222Medicaid