Provider Demographics
NPI:1063071645
Name:FLOURISH COUNSELING MT, LLC
Entity type:Organization
Organization Name:FLOURISH COUNSELING MT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JAI
Authorized Official - Middle Name:KIERON RENE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:206-930-8970
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59771-0385
Mailing Address - Country:US
Mailing Address - Phone:206-930-8970
Mailing Address - Fax:
Practice Address - Street 1:2135 CHARLOTTE ST STE 2
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2741
Practice Address - Country:US
Practice Address - Phone:206-930-8970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty