Basic Information
| Provider Information | |||||||||
| NPI: | 1649227059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACH | ||||||||
| FirstName: | PAUL | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 SCHOOLHOUSE RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178159569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703172694 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 N ORANGE ST | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598022998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063273350 | ||||||||
| FaxNumber: | 4063273396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 01/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PS016937 | PA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | 136 | MT | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 0490569 | 05 | MT | MEDICAID |