Provider Demographics
NPI:1629270640
Name:BABCOCK, SALLY LARSON (LCPC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:LARSON
Last Name:BABCOCK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4779
Mailing Address - Country:US
Mailing Address - Phone:406-586-8038
Mailing Address - Fax:
Practice Address - Street 1:104 E MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4779
Practice Address - Country:US
Practice Address - Phone:406-586-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT451101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000255051Medicaid
MT07527-3OtherBCBS