Healthcare Provider Details

I. General information

NPI: 1154195451
Provider Name (Legal Business Name): EMILY KAYELYN MITTELSTADT SWLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMMA M MITTELSTADT SWLC

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 CONNERY WAY
MISSOULA MT
59808
US

IV. Provider business mailing address

2620 CONNERY WAY
MISSOULA MT
59808-1325
US

V. Phone/Fax

Practice location:
  • Phone: 406-203-9948
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: