Provider Demographics
NPI:1609942069
Name:WOLLERSHEIM, DANETTE M (PHD)
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:M
Last Name:WOLLERSHEIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W KENT AVE
Mailing Address - Street 2:STE I
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6730
Mailing Address - Country:US
Mailing Address - Phone:406-542-7365
Mailing Address - Fax:406-542-1032
Practice Address - Street 1:129 W KENT AVE
Practice Address - Street 2:STE I
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6730
Practice Address - Country:US
Practice Address - Phone:406-542-7365
Practice Address - Fax:406-542-1032
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT249103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT493168Medicaid
MT050841OtherBLUE CROSS
MT493168Medicaid