Basic Information
Provider Information | |||||||||
NPI: | 1376664359 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDWARDS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A., LCPC, LAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2004 HOSPITAL WAY | ||||||||
Address2: |   | ||||||||
City: | WHITEFISH | ||||||||
State: | MT | ||||||||
PostalCode: | 599377858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4068621030 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2004 HOSPITAL WAY | ||||||||
Address2: |   | ||||||||
City: | WHITEFISH | ||||||||
State: | MT | ||||||||
PostalCode: | 599377858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4068621030 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2007 | ||||||||
LastUpdateDate: | 02/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | BBH-LCPC-LIC-13148 | MT | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | BBH-LAC-LIC-13219 | MT | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 736 | NH | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 650 | NH | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 77066380NH01 | 01 |   | ANTHEM | OTHER |