Provider Demographics
NPI:1407347164
Name:VONDERHEIDE, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:VONDERHEIDE
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:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:KILA
Mailing Address - State:MT
Mailing Address - Zip Code:59920-0144
Mailing Address - Country:US
Mailing Address - Phone:406-261-6902
Mailing Address - Fax:
Practice Address - Street 1:100 FINANCIAL DR STE 150
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6002
Practice Address - Country:US
Practice Address - Phone:406-261-6902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT30491101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health