Provider Demographics
NPI:1720216005
Name:CMC REHAB DEPT NEUROPSYCH EVALUATIONS
Entity Type:Organization
Organization Name:CMC REHAB DEPT NEUROPSYCH EVALUATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANE
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-728-4100
Mailing Address - Street 1:2827 FORT MISSOULA RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7408
Mailing Address - Country:US
Mailing Address - Phone:406-728-4100
Mailing Address - Fax:406-327-4545
Practice Address - Street 1:2827 FORT MISSOULA RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7408
Practice Address - Country:US
Practice Address - Phone:406-728-4100
Practice Address - Fax:406-327-4545
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT226103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty