Provider Demographics
NPI:1043916877
Name:FAEGRE, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:FAEGRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 982
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59771-0982
Mailing Address - Country:US
Mailing Address - Phone:612-554-5409
Mailing Address - Fax:
Practice Address - Street 1:105 W MAIN ST STE 2G
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4689
Practice Address - Country:US
Practice Address - Phone:406-384-5774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MT71040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health