Provider Demographics
NPI: | 1821710344 |
---|---|
Name: | MICHELLE R MOLES, LCSW, LAC, LLC |
Entity Type: | Organization |
Organization Name: | MICHELLE R MOLES, LCSW, LAC, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | COUNSELOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MICHELLE |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | MOLES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW, LAC |
Authorized Official - Phone: | 406-529-3629 |
Mailing Address - Street 1: | 800 KENSINGTON AVE STE 211B |
Mailing Address - Street 2: | |
Mailing Address - City: | MISSOULA |
Mailing Address - State: | MT |
Mailing Address - Zip Code: | 59801-5670 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 406-529-3629 |
Mailing Address - Fax: | 406-830-3186 |
Practice Address - Street 1: | 800 KENSINGTON AVE STE 211B |
Practice Address - Street 2: | |
Practice Address - City: | MISSOULA |
Practice Address - State: | MT |
Practice Address - Zip Code: | 59801-5670 |
Practice Address - Country: | US |
Practice Address - Phone: | 406-529-3629 |
Practice Address - Fax: | 406-830-3186 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-09-12 |
Last Update Date: | 2022-09-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Single Specialty |