Provider Demographics
NPI:1205226149
Name:WELLBORN, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WELLBORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 S 72ND ST W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-3538
Mailing Address - Country:US
Mailing Address - Phone:406-651-3122
Mailing Address - Fax:
Practice Address - Street 1:30 MT HIGHWAY 91 S
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-3535
Practice Address - Country:US
Practice Address - Phone:406-683-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT113851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT81-0262019OtherYBGR