Basic Information
| Provider Information | |||||||||
| NPI: | 1093162257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CCCS SMART PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 W MERCURY ST | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597011510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062993448 | ||||||||
| FaxNumber: | 4062993450 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 W MERCURY ST | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597011510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062993448 | ||||||||
| FaxNumber: | 4062993450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2016 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | JENI | ||||||||
| AuthorizedOfficialMiddleName: | LEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED ADDICTION COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 4062993448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.