Provider Demographics
NPI:1700473253
Name:WAKE MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:WAKE MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINCIAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIESER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-261-9127
Mailing Address - Street 1:410 10TH AVE W
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4724
Mailing Address - Country:US
Mailing Address - Phone:406-261-9127
Mailing Address - Fax:
Practice Address - Street 1:428 1ST AVE W
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4836
Practice Address - Country:US
Practice Address - Phone:406-253-1807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)