Basic Information
| Provider Information | |||||||||
| NPI: | 1780257717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TAMMIE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHELTON | ||||||||
| OtherFirstName: | TAMMIE | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 907 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594360907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067992711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 1ST AVE N | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594369245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064673447 | ||||||||
| FaxNumber: | 4064673407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2021 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | BBH-LCPC-LIC-43683 | MT | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YS0200X | 83382 | MT | N | Behavioral Health & Social Service Providers | Counselor | School | 101YM0800X | BBH-LCPC-LIC-43683 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.