Provider Demographics
NPI:1972857308
Name:BIRDWOMAN, ROSALIE
Entity Type:Individual
Prefix:MS
First Name:ROSALIE
Middle Name:
Last Name:BIRDWOMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ROSALIE
Other - Middle Name:
Other - Last Name:BIRDWOMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICENSED ADDICTION C
Mailing Address - Street 1:100 EAGLE FEATHER STREET
Mailing Address - Street 2:
Mailing Address - City:LAME DEER
Mailing Address - State:MT
Mailing Address - Zip Code:59043
Mailing Address - Country:US
Mailing Address - Phone:406-477-4916
Mailing Address - Fax:
Practice Address - Street 1:100 EAGLE FEATHER ST.
Practice Address - Street 2:LAME DEER, MONTANA
Practice Address - City:LAME DEER,
Practice Address - State:MT
Practice Address - Zip Code:59043
Practice Address - Country:US
Practice Address - Phone:406-477-4916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT494101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)