Basic Information
| Provider Information | |||||||||
| NPI: | 1881985653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANKS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MA, LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8169 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598078169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063273350 | ||||||||
| FaxNumber: | 4063273396 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N ORANGE ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598022998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063273350 | ||||||||
| FaxNumber: | 4063273396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 04/27/2011 | ||||||||
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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 | 101YP2500X | 1558 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.