Provider Demographics
NPI:1194425637
Name:SHAFF, MANDI (LAC)
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:SHAFF
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:
Other - Last Name:BOSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:1941 HARRISON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-5499
Mailing Address - Country:US
Mailing Address - Phone:406-221-7435
Mailing Address - Fax:
Practice Address - Street 1:1941 HARRISON AVE STE B
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-5499
Practice Address - Country:US
Practice Address - Phone:406-221-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT42815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)