Healthcare Provider Details

I. General information

NPI: 1164849345
Provider Name (Legal Business Name): WESTERN MONTANA MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

1315 WYOMING STREET
MISSOULA MT
59801
US

V. Phone/Fax

Practice location:
  • Phone: 406-432-9700
  • Fax: 406-541-3035
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number25102
License Number StateMT

VIII. Authorized Official

Name: MS. KIMBERLEY MICHELLE PETERSEN
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: N.P.
Phone: 406-532-9700