Provider Demographics
NPI:1609524172
Name:ALLY PSYCHIATRIC WELLNESS
Entity Type:Organization
Organization Name:ALLY PSYCHIATRIC WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENTRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DE CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:816-800-1308
Mailing Address - Street 1:3701 TRAKKER TRL
Mailing Address - Street 2:SUITE 1B #35
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 MILL TOWN LOOP STE C
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6769
Practice Address - Country:US
Practice Address - Phone:406-404-6711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-14
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1164920088Medicaid