Healthcare Provider Details

I. General information

NPI: 1811657216
Provider Name (Legal Business Name): HEADWATERS WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 MAIN ST
KALISPELL MT
59901-4452
US

IV. Provider business mailing address

118 MAIN ST
KALISPELL MT
59901-4452
US

V. Phone/Fax

Practice location:
  • Phone: 406-219-1104
  • Fax:
Mailing address:
  • Phone: 406-219-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY EPPARD
Title or Position: OWNER/APRN
Credential:
Phone: 406-219-1104