Provider Demographics
NPI:1306296249
Name:WEASELHEAD, SUSAN (LCPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WEASELHEAD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-0336
Mailing Address - Country:US
Mailing Address - Phone:406-529-0582
Mailing Address - Fax:
Practice Address - Street 1:6 13TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5315
Practice Address - Country:US
Practice Address - Phone:406-883-5680
Practice Address - Fax:406-883-8910
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16620101YP2500X
MT16220101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional