Basic Information
| Provider Information | |||||||||
| NPI: | 1306296249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEASELHEAD | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 336 | ||||||||
| Address2: | |||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598650336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065290582 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 13TH AVE E | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598605315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068835680 | ||||||||
| FaxNumber: | 4068838910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2016 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 16620 | MT | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 16220 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.