Provider Demographics
NPI:1578891289
Name:MONTANA THERAPY
Entity Type:Organization
Organization Name:MONTANA THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:PROF
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDRECHAK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:406-622-5955
Mailing Address - Street 1:2111 WASHINGTON
Mailing Address - Street 2:PO BOX 806
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442
Mailing Address - Country:US
Mailing Address - Phone:406-622-5955
Mailing Address - Fax:406-622-5477
Practice Address - Street 1:2111 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442
Practice Address - Country:US
Practice Address - Phone:406-622-5955
Practice Address - Fax:406-622-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20513RN363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTB05802Medicare UPIN