Provider Demographics
NPI:1962053314
Name:ANDERSON, IAN
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5219
Mailing Address - Country:US
Mailing Address - Phone:406-580-5071
Mailing Address - Fax:
Practice Address - Street 1:1807 W DICKERSON ST STE D
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-1311
Practice Address - Country:US
Practice Address - Phone:406-219-8321
Practice Address - Fax:406-215-4554
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-38594101YM0800X
MTBBH-LCPC-LIC-55424101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty