Provider Demographics
NPI:1740682681
Name:BIRKELO, AMY (LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BIRKELO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 N HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-6401
Mailing Address - Country:US
Mailing Address - Phone:406-593-0399
Mailing Address - Fax:406-496-6035
Practice Address - Street 1:630 W MERCURY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1510
Practice Address - Country:US
Practice Address - Phone:406-299-3448
Practice Address - Fax:406-299-3450
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLAC-LAC-LIC-4124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)