Provider Demographics
NPI:1649300567
Name:SOUTHWEST CHEMICAL DEPENDENCY PROGRAM
Entity type:Organization
Organization Name:SOUTHWEST CHEMICAL DEPENDENCY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:406-222-2812
Mailing Address - Street 1:PO BOX 1587
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-5587
Mailing Address - Country:US
Mailing Address - Phone:406-222-2812
Mailing Address - Fax:406-222-4764
Practice Address - Street 1:430 E PARK ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-2755
Practice Address - Country:US
Practice Address - Phone:406-222-2812
Practice Address - Fax:406-222-4764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MT089288261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0320076Medicaid
MT760140OtherPROVIDER NUMBER