Basic Information
| Provider Information | |||||||||
| NPI: | 1548752389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTELL | ||||||||
| FirstName: | ATHENA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1732 S 72ND ST W | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591063538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066552100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1732 72ND ST. W. | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066552100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2018 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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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 | 101YA0400X | BBH-LAC-LIC-30187 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.