Provider Demographics
NPI:1740928449
Name:GRUPENHOFF, MARY MARGARET (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:GRUPENHOFF
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 1:2105 OTTAWA ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-6115
Mailing Address - Country:US
Mailing Address - Phone:509-540-0865
Mailing Address - Fax:
Practice Address - Street 1:775 W GOLD ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2301
Practice Address - Country:US
Practice Address - Phone:406-496-2380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-55515101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)