Provider Demographics
NPI:1619465788
Name:MEDICINE LODGE COUNSELING PLLC
Entity Type:Organization
Organization Name:MEDICINE LODGE COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC LAC
Authorized Official - Phone:406-360-8470
Mailing Address - Street 1:14098 JENNY ANN CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5386
Mailing Address - Country:US
Mailing Address - Phone:406-360-8470
Mailing Address - Fax:
Practice Address - Street 1:2809 GREAT NORTHERN LOOP STE 210-5
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1749
Practice Address - Country:US
Practice Address - Phone:406-360-8470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty