MEDICARE: MS. NADINE M. WISNIEWSKI PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	MT254	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50641	OTHER	MT	BLUE CROSS

General Provider Information

NPI Number	:	1245357177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NADINE M. WISNIEWSKI PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 1171
Second Line	:
City	:	FLORENCE
State	:	MT
Zip	:	59833-1171
Country	:	US
Telephone Number	:	406-370-1727
Fax Number	:

Provider Business Practice Location Address
First Line	:	27 FORT MISSOULA RD
Second Line	:	STE B4
City	:	MISSOULA
State	:	MT
Zip	:	59804-7206
Country	:	US
Telephone Number	:	406-370-1727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2007
Last Update Date	:	01/14/2019

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