Provider Demographics
NPI:1669423778
Name:CONWAY, MICHAELA (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:CONWAY
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 1:1008 BURLINGTON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-549-7104
Mailing Address - Fax:406-542-2785
Practice Address - Street 1:415 N HIGGINS
Practice Address - Street 2:SUITE 15
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-721-3000
Practice Address - Fax:406-721-5912
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT637LCSW101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0503540Medicaid