Provider Demographics
NPI:1912624594
Name:HEAVYRUNNER, ANDREW C
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
Last Name:HEAVYRUNNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STEPHENS AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6607
Mailing Address - Country:US
Mailing Address - Phone:406-829-9515
Mailing Address - Fax:
Practice Address - Street 1:1511 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-3629
Practice Address - Country:US
Practice Address - Phone:406-829-9515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT58896101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor