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General NPI Number Information
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NPI Number | 1942098652
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Entity Type | Individual
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Provider Name | DESERIE BONNIE KELLEY
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Gender | Female
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Dates
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Enumeration Date | 04/30/2025
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 2210 MULLAN RD
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City | MISSOULA
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State | MT
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Zip | 59808-2059
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Country | US
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Telephone | 406-493-7041
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Fax |
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Provider Business Mailing Address
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Address Line | 401 RAILROAD ST W
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City | MISSOULA
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State | MT
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Zip | 59802-4178
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Country | US
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Telephone | 406-258-4789
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Fax | 406-258-4732
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | BBH-BHPS-CRT-78905
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License Number State | MT
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