Provider Demographics
NPI:1083791008
Name:WAHLBERG, JAMES LEE (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
Last Name:WAHLBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 FORT MISSOULA ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7401
Mailing Address - Country:US
Mailing Address - Phone:406-728-8818
Mailing Address - Fax:406-327-4552
Practice Address - Street 1:2831 FORT MISSOULA ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7401
Practice Address - Country:US
Practice Address - Phone:406-728-8818
Practice Address - Fax:406-327-4552
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT109103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT492596Medicaid
MT51670OtherBCBS