Provider Demographics
NPI:1710950571
Name:SCHALL, GRACIA L (MS LCPC)
Entity Type:Individual
Prefix:MS
First Name:GRACIA
Middle Name:L
Last Name:SCHALL
Suffix:
Gender:F
Credentials:MS LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 SOUTH AVE W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7804
Mailing Address - Country:US
Mailing Address - Phone:406-721-1774
Mailing Address - Fax:406-721-1774
Practice Address - Street 1:1640 SOUTH AVENUE WEST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-721-1774
Practice Address - Fax:406-721-1774
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT55 LCPC103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0257074Medicaid
MT075310OtherBLUE CROSS