Provider Demographics
NPI:1689727307
Name:TOLLAKSON, TERRY L (MA LCPC RPTS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:TOLLAKSON
Suffix:
Gender:F
Credentials:MA LCPC RPTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 W 6TH AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601
Mailing Address - Country:US
Mailing Address - Phone:406-449-4800
Mailing Address - Fax:406-449-1393
Practice Address - Street 1:34 W 6TH AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601
Practice Address - Country:US
Practice Address - Phone:406-449-4800
Practice Address - Fax:406-449-1393
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC556103T00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000253890Medicaid