Provider Demographics
NPI:1710659115
Name:SOURCE COUNSELING COLLECTIVE
Entity Type:Organization
Organization Name:SOURCE COUNSELING COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-589-5512
Mailing Address - Street 1:4558 PERRY ST APT B
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6661
Mailing Address - Country:US
Mailing Address - Phone:406-589-5512
Mailing Address - Fax:
Practice Address - Street 1:2415 W MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3809
Practice Address - Country:US
Practice Address - Phone:406-589-5512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-04
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty