Provider Demographics
NPI:1649087354
Name:STAKER, ALLYSSA (MS, SWLC)
Entity type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:
Last Name:STAKER
Suffix:
Gender:X
Credentials:MS, SWLC
Other - Prefix:
Other - First Name:ALLYSSA
Other - Middle Name:
Other - Last Name:RICHIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1924 W STEVENS ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-7043
Mailing Address - Country:US
Mailing Address - Phone:406-595-3746
Mailing Address - Fax:406-578-1363
Practice Address - Street 1:1924 W STEVENS ST STE 202
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7043
Practice Address - Country:US
Practice Address - Phone:406-595-3746
Practice Address - Fax:406-578-1363
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT76714101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health