Provider Demographics
NPI:1699519611
Name:WILLARD, MARY (SWLC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:SWLC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1206
Mailing Address - Country:US
Mailing Address - Phone:406-544-1668
Mailing Address - Fax:
Practice Address - Street 1:106 ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1206
Practice Address - Country:US
Practice Address - Phone:406-544-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-715991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical