Provider Demographics
NPI:1699081125
Name:EWALT, KELLY ANNE (LCPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:EWALT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:EWALT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:305 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-3625
Mailing Address - Country:US
Mailing Address - Phone:406-249-9153
Mailing Address - Fax:406-892-4606
Practice Address - Street 1:305 1ST AVE W
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-3619
Practice Address - Country:US
Practice Address - Phone:406-249-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-22
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT683101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health