Healthcare Provider Details

I. General information

NPI: 1437037041
Provider Name (Legal Business Name): KELLY RIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3335 LT MOSS RD
MISSOULA MT
59804-7222
US

IV. Provider business mailing address

3335 LT MOSS RD
MISSOULA MT
59804-7222
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-2202
  • Fax:
Mailing address:
  • Phone: 406-543-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-PCLC-LIC-81040
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: