Provider Demographics
NPI:1881290302
Name:BOULE SOPHIA LLC
Entity type:Organization
Organization Name:BOULE SOPHIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-491-2898
Mailing Address - Street 1:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-1642
Mailing Address - Country:US
Mailing Address - Phone:406-491-2898
Mailing Address - Fax:
Practice Address - Street 1:41582 BAYPOINT RD
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-8584
Practice Address - Country:US
Practice Address - Phone:406-491-2898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1200619724101OtherDRIVERS LICENSE