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General NPI Number Information
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NPI Number | 1164849345
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Entity Type | Organization
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Legal Business Name | WESTERN MONTANA MENTAL HEALTH CENTER
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Dates
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Enumeration Date | 03/25/2014
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Last Update Date | 03/25/2014
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Provider Practice Location Address
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Address Line | 1315 WYOMING ST
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City | MISSOULA
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State | MT
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Zip | 59801-1725
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Country | US
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Telephone | 406-432-9700
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Fax | 406-541-3035
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Provider Business Mailing Address
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Address Line | 1315 WYOMING STREET
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City | MISSOULA
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State | MT
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Zip | 59801
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHIATRIC NURSE PRACTITIONER
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Name | MS. KIMBERLEY MICHELLE PETERSEN
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Credential | N.P.
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Telephone | 406-532-9700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 25102
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License Number State | MT
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