Provider Demographics
NPI:1699482216
Name:SIMONSON, LAURIE (LAC)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 MONTICELLO PL
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-8685
Mailing Address - Country:US
Mailing Address - Phone:406-396-1592
Mailing Address - Fax:
Practice Address - Street 1:202 BROOKS ST STE 300
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4019
Practice Address - Country:US
Practice Address - Phone:406-926-1453
Practice Address - Fax:406-396-1454
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-57673101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)