Provider Demographics
NPI:1558706945
Name:EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC
Entity Type:Organization
Organization Name:EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC
Other - Org Name:ESGW BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-771-3762
Mailing Address - Street 1:425 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-2507
Mailing Address - Country:US
Mailing Address - Phone:406-771-3754
Mailing Address - Fax:
Practice Address - Street 1:524 S 9TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5072
Practice Address - Country:US
Practice Address - Phone:208-454-8555
Practice Address - Fax:208-454-8828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health