=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265752034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN HOME MONTANA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2010
-----------------------------------------------------
Last Update Date | 01/13/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4720 23RD AVE
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59803-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-541-4663
-----------------------------------------------------
Fax | 406-541-4662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4720 23RD AVE
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59803-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-541-4663
-----------------------------------------------------
Fax | 406-541-4662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | GRETA JERNBERG
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 406-541-4663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 709LCSW
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 13491
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 13491
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------