Provider Demographics
NPI:1255401576
Name:FAHLGREN, MARY KATHRYN (LCPC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHRYN
Last Name:FAHLGREN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:MT
Mailing Address - Zip Code:59230-1729
Mailing Address - Country:US
Mailing Address - Phone:406-228-8922
Mailing Address - Fax:
Practice Address - Street 1:316 1ST ALY N
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:MT
Practice Address - Zip Code:59230-1817
Practice Address - Country:US
Practice Address - Phone:406-228-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1160101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000256530Medicaid