MEDICARE: MR. DAVID E WILTFONG LCSW

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	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	SWP-LCSW-LIC-12360	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467829390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID E WILTFONG LCSW

Provider Business Mailing Address
First Line	:	PO BOX 16332
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1830
Country	:	US
Telephone Number	:	406-241-5816
Fax Number	:

Provider Business Practice Location Address
First Line	:	2423 MULLAN RD
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1827
Country	:	US
Telephone Number	:	406-241-5816
Fax Number	:

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

Provider Enumeration Date	:	08/26/2015
Last Update Date	:	11/20/2024

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