Healthcare Provider Details

I. General information

NPI: 1902674310
Provider Name (Legal Business Name): ELIZABETH NICOLE TALBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 02/21/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SW HIGGINS AVE STE 107
MISSOULA MT
59803-1489
US

IV. Provider business mailing address

307 19TH AVE W
POLSON MT
59860-4028
US

V. Phone/Fax

Practice location:
  • Phone: 406-214-3810
  • Fax:
Mailing address:
  • Phone: 406-214-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-SWLC-LIC-63845
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: