Provider Demographics
NPI:1063813152
Name:LITTLE LEAF, KATHLEEN I
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LITTLE LEAF
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7931
Mailing Address - Country:US
Mailing Address - Phone:406-829-9515
Mailing Address - Fax:406-829-9519
Practice Address - Street 1:830 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7931
Practice Address - Country:US
Practice Address - Phone:406-829-9515
Practice Address - Fax:406-829-9519
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1199101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)