Provider Demographics
NPI:1760956098
Name:ELKHORN PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:ELKHORN PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FOREST
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW LMFT
Authorized Official - Phone:406-531-0702
Mailing Address - Street 1:PO BOX 4821
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-4821
Mailing Address - Country:US
Mailing Address - Phone:406-531-0702
Mailing Address - Fax:
Practice Address - Street 1:101 E BROADWAY ST STE 405
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4510
Practice Address - Country:US
Practice Address - Phone:406-531-0702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty