Basic Information
| Provider Information | |||||||||
| NPI: | 1407245756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YELLOWSTONE BOYS AND GIRLS RANCH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | YBGR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3212 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591013814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066513122 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3212 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591013814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066513122 | ||||||||
| FaxNumber: | 4066512783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2015 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAVERS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4066552109 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | SWP-LCPC-LIC-11057 | MT | N | Agencies | Community/Behavioral Health | 251S00000X | SWP-LCPC-LIC-8348 | MT | Y | Agencies | Community/Behavioral Health |
No ID Information.