Provider Demographics
NPI:1578737250
Name:KILLEBREW-HALL, PATI JO (MT 880 LAC)
Entity Type:Individual
Prefix:MRS
First Name:PATI
Middle Name:JO
Last Name:KILLEBREW-HALL
Suffix:
Gender:F
Credentials:MT 880 LAC
Other - Prefix:
Other - First Name:PATI
Other - Middle Name:
Other - Last Name:KILLEBREW-HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:1220 CENTRAL AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401
Mailing Address - Country:US
Mailing Address - Phone:406-268-1587
Mailing Address - Fax:406-268-1572
Practice Address - Street 1:1220 CENTRAL AVE STE 1B
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401
Practice Address - Country:US
Practice Address - Phone:406-268-1587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT880101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)