Basic Information
| Provider Information | |||||||||
| NPI: | 1871958041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUFFALO | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | BELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | SHAWNA | ||||||||
| OtherMiddleName: | BELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 880 | ||||||||
| Address2: | |||||||||
| City: | ST. IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067453529 | ||||||||
| Practice Location | |||||||||
| Address1: | 35401 MISSION DR. | ||||||||
| Address2: | |||||||||
| City: | ST. IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067453529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | BBH-LCSW-LIC-73 | MT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 73 | MT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.