Provider Demographics
NPI:1669667275
Name:GOOD MEDICINE THERAPY CENTER PLLC
Entity Type:Organization
Organization Name:GOOD MEDICINE THERAPY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LCSWLAC,CMHP
Authorized Official - Phone:406-293-7116
Mailing Address - Street 1:803 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2107
Mailing Address - Country:US
Mailing Address - Phone:406-293-7116
Mailing Address - Fax:406-293-4029
Practice Address - Street 1:803 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2107
Practice Address - Country:US
Practice Address - Phone:406-293-7116
Practice Address - Fax:406-293-4029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT799LCSW251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0044707Medicaid