Provider Demographics
NPI:1902038201
Name:DERBY, CAROL FAYE (LAC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:FAYE
Last Name:DERBY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N LAST CHANCE GULCH
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4125
Mailing Address - Country:US
Mailing Address - Phone:406-447-3265
Mailing Address - Fax:
Practice Address - Street 1:111 N LAST CHANCE GULCH
Practice Address - Street 2:SUITE 1E
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4125
Practice Address - Country:US
Practice Address - Phone:406-447-3265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1105101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)