Healthcare Provider Details

I. General information

NPI: 1053751487
Provider Name (Legal Business Name): EATING DISORDER CENTER OF MONTANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2013
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 S WILLSON AVE SUITE 102
BOZEMAN MT
59715-6232
US

IV. Provider business mailing address

14 S WILLSON AVE SUITE 102
BOZEMAN MT
59715-6232
US

V. Phone/Fax

Practice location:
  • Phone: 805-637-4900
  • Fax: 406-551-1209
Mailing address:
  • Phone: 805-637-4900
  • Fax: 406-551-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENI RUTH GOCHIN
Title or Position: CLINICAL DIRECTOR
Credential: LMFT, LCPC
Phone: 805-637-4900