Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | BBH-PCLC-LIC-42761 | MT |
N | 101YS0200X | School Counselor | 83795 | MT |
NPI | 1164038584 |
---|---|
Provider Name | Tyson Roe |
First Address | Kalispell, MT 59901-5776 |
Second Address | Kalispell, MT 59901-5776 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2020 |
Last Update Date | 21/09/2020 |