Provider Demographics
NPI:1306691860
Name:DALSTROM, TAYLOR MICHAEL (PCLC)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MICHAEL
Last Name:DALSTROM
Suffix:
Gender:M
Credentials:PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6835
Mailing Address - Country:US
Mailing Address - Phone:770-584-5412
Mailing Address - Fax:
Practice Address - Street 1:2282 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-8499
Practice Address - Country:US
Practice Address - Phone:406-890-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-42763101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health