Provider Demographics
NPI:1922834373
Name:CHASE, SAMANTHA ELIZABETH (ACLC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:CHASE
Suffix:
Gender:F
Credentials:ACLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 WAPIKIYA DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1230
Mailing Address - Country:US
Mailing Address - Phone:208-419-1830
Mailing Address - Fax:
Practice Address - Street 1:202 BROOKS ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4019
Practice Address - Country:US
Practice Address - Phone:406-926-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-72160101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)