Provider Demographics
NPI:1841437142
Name:GLACIER PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:GLACIER PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SIMON-THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:406-253-7745
Mailing Address - Street 1:723 5TH AVE E
Mailing Address - Street 2:SUITE 126S
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5321
Mailing Address - Country:US
Mailing Address - Phone:406-253-7745
Mailing Address - Fax:406-257-9721
Practice Address - Street 1:723 5TH AVE E
Practice Address - Street 2:SUITE 126S
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5321
Practice Address - Country:US
Practice Address - Phone:406-253-7745
Practice Address - Fax:406-257-9721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT355103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty