Provider Demographics
NPI:1568837730
Name:LEIGH FAHLQUIST, LLC
Entity Type:Organization
Organization Name:LEIGH FAHLQUIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:TABOR
Authorized Official - Last Name:FAHLQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:406-465-1276
Mailing Address - Street 1:PO BOX 9717
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-9717
Mailing Address - Country:US
Mailing Address - Phone:406-465-1276
Mailing Address - Fax:
Practice Address - Street 1:1159 TOUCAN RD.
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602
Practice Address - Country:US
Practice Address - Phone:406-465-1276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1005251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health