Provider Demographics
NPI:1528310026
Name:KOO, JAMES (LCSW, RAS)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:KOO
Suffix:
Gender:M
Credentials:LCSW, RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 305
Mailing Address - Street 2:BOX 772
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96218-0008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 REGENT ST.
Practice Address - Street 2:SUITE 207
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-329-4502
Practice Address - Fax:406-329-4512
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAK1202230953101YA0400X
OR49621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical