Healthcare Provider Details

I. General information

NPI: 1760703474
Provider Name (Legal Business Name): INTERMOUNTAIN DEACONNESS HOME FOR CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 2ND AVE W STE A
KALISPELL MT
59901-4867
US

IV. Provider business mailing address

3240 DREDGE DR
HELENA MT
59602-0548
US

V. Phone/Fax

Practice location:
  • Phone: 406-755-4022
  • Fax: 406-755-4023
Mailing address:
  • Phone: 406-442-7920
  • Fax: 406-442-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

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