Provider Demographics
NPI:1518954106
Name:INTERMOUNTAIN DEACONESS HOME
Entity Type:Organization
Organization Name:INTERMOUNTAIN DEACONESS HOME
Other - Org Name:INTERMOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-457-4822
Mailing Address - Street 1:3240 DREDGE DR
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-0548
Mailing Address - Country:US
Mailing Address - Phone:406-457-4820
Mailing Address - Fax:406-442-7949
Practice Address - Street 1:500 S. LAMBORN ST.
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-5417
Practice Address - Country:US
Practice Address - Phone:406-442-7920
Practice Address - Fax:406-442-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT65602084P0804X
251B00000X, 261QM0855X
MT0007148-001251S00000X
MT7148251S00000X, 322D00000X
MT0007148-005320800000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118301001Medicaid
AKSP516MTMedicaid
AKHS775PIMedicaid
AKOT287MTMedicaid
WY118301000Medicaid
AKHS775PIMedicaid