Provider Demographics
NPI:1467829390
Name:WILTFONG, DAVID E (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:WILTFONG
Suffix:
Gender:M
Credentials:LCSW
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 16332
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1830
Mailing Address - Country:US
Mailing Address - Phone:406-241-5816
Mailing Address - Fax:
Practice Address - Street 1:2415 MULLAN RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1827
Practice Address - Country:US
Practice Address - Phone:406-241-5816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSWP-LCSW-LIC-123601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1467829390Medicaid