Provider Demographics
NPI:1598202475
Name:MCINTYRE, RANDAL (LAC)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:MCINTYRE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E PARK AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-2320
Mailing Address - Country:US
Mailing Address - Phone:406-563-7038
Mailing Address - Fax:406-563-7685
Practice Address - Street 1:307 E PARK AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2320
Practice Address - Country:US
Practice Address - Phone:406-563-7038
Practice Address - Fax:406-563-7685
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-1256101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)