Basic Information
| Provider Information | |||||||||
| NPI: | 1265556757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YELLOWSTONE BOYS AND GIRLS RANCH | ||||||||
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| OtherOrganizationName: | MENTAL HEALTH CENTER AND CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1732 S 72ND ST W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591063538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066552100 | ||||||||
| FaxNumber: | 4066512783 | ||||||||
| Practice Location | |||||||||
| Address1: | 1732 S 72ND ST W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066552100 | ||||||||
| FaxNumber: | 4066512783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | CHAVERS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4066552109 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QM0855X | 11000 | MT | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | 1047 | MT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QM0855X | 12265 | MT | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0042770 | 05 | MT | MEDICAID | 4309903 | 05 | MT | MEDICAID | 0255442 | 05 | MT | MEDICAID | 0502384 | 05 | MO | MEDICAID | 0069343 | 05 | MT | MEDICAID | 0039819 | 05 | MT | MEDICAID | 0350625 | 05 | MT | MEDICAID | 4302938 | 05 | MT | MEDICAID |