Healthcare Provider Details

I. General information

NPI: 1518954106
Provider Name (Legal Business Name): INTERMOUNTAIN DEACONESS HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S. LAMBORN ST.
HELENA MT
59601-5417
US

IV. Provider business mailing address

3240 DREDGE DR
HELENA MT
59602-0548
US

V. Phone/Fax

Practice location:
  • Phone: 406-442-7920
  • Fax: 406-442-7949
Mailing address:
  • Phone: 406-457-4820
  • Fax: 406-442-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number6560
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0007148-001
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number7148
License Number StateMT
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number0007148-005
License Number StateMT
# 7
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number7148
License Number StateMT
# 8
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number0007148-005
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier118301001
Identifier TypeMEDICAID
Identifier StateWY
Identifier Issuer
# 2
IdentifierSP516MT
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 3
IdentifierHS775PI
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 4
IdentifierOT287MT
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 5
Identifier118301000
Identifier TypeMEDICAID
Identifier StateWY
Identifier Issuer

VIII. Authorized Official

Name: MRS. JENNIFER WILLIAMS
Title or Position: CAO
Credential:
Phone: 406-457-4822