Provider Demographics
NPI:1558530683
Name:PROVIDENCE HEALTH & SERVICES MT
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES MT
Other - Org Name:PMT MT URGENT MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR REIMB REG STRAT/ASST SEC ENROLL
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-3029
Mailing Address - Fax:
Practice Address - Street 1:900 N ORANGE ST
Practice Address - Street 2:STE 102
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2951
Practice Address - Country:US
Practice Address - Phone:406-327-3029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES MT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-22
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MT17652363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN