Provider Demographics
NPI:1851422299
Name:DEGOLIER, ROB (LAC)
Entity Type:Individual
Prefix:MR
First Name:ROB
Middle Name:
Last Name:DEGOLIER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10926
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-3926
Mailing Address - Country:US
Mailing Address - Phone:406-885-3726
Mailing Address - Fax:
Practice Address - Street 1:29 1/2 W COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2800
Practice Address - Country:US
Practice Address - Phone:406-885-3726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1143101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000076391OtherBLUE CROSS BLUE SHIELD
MT0320372Medicaid