Provider Demographics
NPI:1265223382
Name:GANNON, CHASE
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:GANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 FLOOD RD
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-6442
Mailing Address - Country:US
Mailing Address - Phone:406-868-7502
Mailing Address - Fax:
Practice Address - Street 1:202 BROOKS ST STE 300
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4019
Practice Address - Country:US
Practice Address - Phone:406-926-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-79686103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)