Provider Demographics
NPI:1104064195
Name:PEDRO, JANIS M (LCSW)
Entity type:Individual
Prefix:MS
First Name:JANIS
Middle Name:M
Last Name:PEDRO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#20 5TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-9299
Mailing Address - Country:US
Mailing Address - Phone:307-272-5881
Mailing Address - Fax:
Practice Address - Street 1:20 5TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-2913
Practice Address - Country:US
Practice Address - Phone:307-272-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9351041C0700X
WYLCSW-5241041C0700X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1104064195Medicaid