Provider Demographics
NPI:1912359639
Name:WAHLBERG PSYCHOLOGY OFFICE, PC
Entity Type:Organization
Organization Name:WAHLBERG PSYCHOLOGY OFFICE, PC
Other - Org Name:JAMES WAHLBERG, PH.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WAHLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:406-728-8818
Mailing Address - Street 1:2831 FORT MISSOULA RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7419
Mailing Address - Country:US
Mailing Address - Phone:406-728-8818
Mailing Address - Fax:
Practice Address - Street 1:2831 FORT MISSOULA RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7419
Practice Address - Country:US
Practice Address - Phone:406-728-8818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAHLBERG PSYCHOLOGY OFFICE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT109251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT51670OtherBLUE CROSS BLUE SHIELD
MT492596Medicaid
000005167Medicare UPIN