Provider Demographics
NPI:1376304592
Name:HENNESSY, AMELIA ELIZABETH
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:ELIZABETH
Last Name:HENNESSY
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 1:15 BRIDGER PINES RD UNIT B1
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8605
Mailing Address - Country:US
Mailing Address - Phone:907-903-4476
Mailing Address - Fax:
Practice Address - Street 1:950 STONERIDGE DR STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7063
Practice Address - Country:US
Practice Address - Phone:406-624-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health