Healthcare Provider Details

I. General information

NPI: 1629083506
Provider Name (Legal Business Name): SUSAN E BODURTHA RN, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 WINDWARD WAY
KALISPELL MT
59901-2680
US

IV. Provider business mailing address

T-9 FORT MISSOULA
MISSOULA MT
59804-7202
US

V. Phone/Fax

Practice location:
  • Phone: 406-257-1336
  • Fax: 406-257-1353
Mailing address:
  • Phone: 406-532-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN12218
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: