Provider Demographics
NPI:1578703005
Name:RICHARD, CAROL GEORGEANNE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:GEORGEANNE
Last Name:RICHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442-0459
Mailing Address - Country:US
Mailing Address - Phone:406-622-3211
Mailing Address - Fax:
Practice Address - Street 1:1308 FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:FT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442
Practice Address - Country:US
Practice Address - Phone:406-622-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT196101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)