Provider Demographics
NPI:1952936254
Name:BIGBACK, ROSALYN MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:MARIE
Last Name:BIGBACK
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 1:10 4TH ST W
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:MT
Mailing Address - Zip Code:59034-1802
Mailing Address - Country:US
Mailing Address - Phone:406-867-4105
Mailing Address - Fax:406-867-4103
Practice Address - Street 1:10 4TH ST W
Practice Address - Street 2:
Practice Address - City:HARDIN
Practice Address - State:MT
Practice Address - Zip Code:59034-1802
Practice Address - Country:US
Practice Address - Phone:406-867-4105
Practice Address - Fax:406-867-4103
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-42731101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)