=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558530683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE HEALTH & SERVICES MT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2008
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 N ORANGE ST STE 102
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-2951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-327-3029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31001 - 4114
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91110-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY ENROLLMENT
-----------------------------------------------------
Name | DONALD W ANDERSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-358-9786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 17652
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------