Provider Demographics
NPI:1528117983
Name:KING, MOLLY SIDDOWAY (LCPC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:SIDDOWAY
Last Name:KING
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4760
Mailing Address - Country:US
Mailing Address - Phone:406-587-8069
Mailing Address - Fax:406-586-8327
Practice Address - Street 1:104 E MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4760
Practice Address - Country:US
Practice Address - Phone:406-587-8069
Practice Address - Fax:406-586-8327
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC - 669101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT74616OtherBCBS PROVIDER #