Provider Demographics
NPI:1598970568
Name:MCLAVERTY, DIANE MARIE (LCPC, LAC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:MCLAVERTY
Suffix:
Gender:F
Credentials:LCPC, LAC
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 255
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MT
Mailing Address - Zip Code:59825-0255
Mailing Address - Country:US
Mailing Address - Phone:406-728-5224
Mailing Address - Fax:406-728-5224
Practice Address - Street 1:1119 W KENT AVE STE D
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6633
Practice Address - Country:US
Practice Address - Phone:406-728-5224
Practice Address - Fax:406-728-5224
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT415101YA0400X
MT187101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0257312Medicaid