Healthcare Provider Details

I. General information

NPI: 1366308140
Provider Name (Legal Business Name): PONDEROSA HEALING WATERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2025
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 1ST AVE
ST IGNATIUS MT
59865-7748
US

IV. Provider business mailing address

PO BOX 548
RONAN MT
59864-0548
US

V. Phone/Fax

Practice location:
  • Phone: 406-880-7305
  • Fax:
Mailing address:
  • Phone: 406-880-7305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ANGELA CHRISTINE EVANS
Title or Position: LAC, SWLC, OWNER
Credential:
Phone: 406-880-7305