Provider Demographics
NPI:1194364091
Name:PERUSICH, TOMMIE LYNN (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:TOMMIE
Middle Name:LYNN
Last Name:PERUSICH
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3911
Mailing Address - Country:US
Mailing Address - Phone:406-541-4673
Mailing Address - Fax:
Practice Address - Street 1:1120 CEDAR ST.
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-541-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT155842363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0290819Medicaid