Provider Demographics
NPI:1871618074
Name:SOUTHWEST CHEMICAL DEPENDENCY PROGRAM
Entity type:Organization
Organization Name:SOUTHWEST CHEMICAL DEPENDENCY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ADDICTION COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:406-683-4305
Mailing Address - Street 1:730 N MONTANA ST
Mailing Address - Street 2:P.O. BOX 527
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-8497
Mailing Address - Country:US
Mailing Address - Phone:406-683-4305
Mailing Address - Fax:406-683-9767
Practice Address - Street 1:730 N MONTANA ST
Practice Address - Street 2:SUITE 9
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-8497
Practice Address - Country:US
Practice Address - Phone:406-683-4305
Practice Address - Fax:406-683-9767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT261QR0404X251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0320076Medicaid