Provider Demographics
NPI:1336625862
Name:MOTHKA, ANGELICA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIE
Last Name:MOTHKA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 HALF HITCH DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5438
Mailing Address - Country:US
Mailing Address - Phone:406-552-9188
Mailing Address - Fax:
Practice Address - Street 1:2809 CONNERY WAY STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1955
Practice Address - Country:US
Practice Address - Phone:406-552-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-314481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical