Healthcare Provider Details

I. General information

NPI: 1427886571
Provider Name (Legal Business Name): CLARA LEANNE WIEDERHOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 E MAIN STREET
BOZEMAN MT
59715
US

IV. Provider business mailing address

1315 E MAIN ST
BOZEMAN MT
59715-3850
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-2477
  • Fax:
Mailing address:
  • Phone: 406-558-3403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberPSY-BA-LIC-6209
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: