Basic Information
| Provider Information | |||||||||
| NPI: | 1427612522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORRELL | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | DELPHINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 880 | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598650880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454409 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 MISSION DR | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598659676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2019 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BBH-ACLC-LIC-33004 | MT | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YA0400X | BBH-ACLC-LIC-33004 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.