Healthcare Provider Details

I. General information

NPI: 1306202163
Provider Name (Legal Business Name): WESTERN MONTANA MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 13TH AVE EAST
POLSON MT
59860
US

IV. Provider business mailing address

140 N RUSSELL ST
MISSOULA MT
59801-1704
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-8400
  • Fax: 406-543-9316
Mailing address:
  • Phone: 406-532-8400
  • Fax: 406-224-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number12652
License Number StateMT

VIII. Authorized Official

Name: JODI DALY
Title or Position: CEO
Credential: PHD
Phone: 406-532-8400