Provider Demographics
NPI:1528574423
Name:HETHERINGTON, MICHAEL WAYNE (LCPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:HETHERINGTON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 LASSO AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-8039
Mailing Address - Country:US
Mailing Address - Phone:406-570-4692
Mailing Address - Fax:
Practice Address - Street 1:4255 KIMBERWICKE ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-5700
Practice Address - Country:US
Practice Address - Phone:406-522-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-26162101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1477745370Medicaid