WESTERN MONTANA MENTAL HEALTH CENTER

Provider Demographics

• NPI: 1912079328
• Name: WESTERN MONTANA MENTAL HEALTH CENTER
• Entity Type: Organization
• Organization Name: WESTERN MONTANA MENTAL HEALTH CENTER
• Authorized Official - Title/Position: CHIEF ADMINISTRATIVE OFFICER
• Authorized Official - First Name: CORY
• Authorized Official - Last Name: DESTEIN
• Authorized Official - Phone: 406-532-8400
• Mailing Address - Street 1: 1321 WYOMING ST
• Mailing Address - City: MISSOULA
• Mailing Address - State: MT
• Mailing Address - Zip Code: 59801-1725
• Mailing Address - Country: US
• Mailing Address - Phone: 406-532-8400
• Mailing Address - Fax: 406-224-4402
• Practice Address - Street 1: 1321 WYOMING ST
• Practice Address - City: MISSOULA
• Practice Address - State: MT
• Practice Address - Zip Code: 59801-1725
• Practice Address - Country: US
• Practice Address - Phone: 406-532-8400
• Practice Address - Fax: 406-224-4402
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-11-14
• Last Update Date: 2024-05-28

Provider Licenses

State	License ID	Taxonomies
		101YA0400X, 101YP2500X, 1041C0700X, 2084P0800X, 320800000X, 363A00000X, 363LP0808X
MT	11034	251B00000X, 251S00000X, 261QM0801X, 261QM0850X, 261QM0855X
MT	258 07	261QR0405X
MT	13459	323P00000X, 324500000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	261QM0801X	Ambulatory Health Care Facilities	Clinic/Center	Mental Health (Including Community Mental Health Center)
No	101YA0400X	Behavioral Health & Social Service Providers	Counselor	Addiction (Substance Use Disorder)	Group - Multi-Specialty
No	101YP2500X	Behavioral Health & Social Service Providers	Counselor	Professional	Group - Multi-Specialty
No	1041C0700X	Behavioral Health & Social Service Providers	Social Worker	Clinical	Group - Multi-Specialty
No	2084P0800X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Psychiatry	Group - Multi-Specialty
No	251B00000X	Agencies	Case Management
No	251S00000X	Agencies	Community/Behavioral Health
No	261QM0850X	Ambulatory Health Care Facilities	Clinic/Center	Adult Mental Health
No	261QM0855X	Ambulatory Health Care Facilities	Clinic/Center	Adolescent and Children Mental Health
No	261QR0405X	Ambulatory Health Care Facilities	Clinic/Center	Rehabilitation, Substance Use Disorder
No	320800000X	Residential Treatment Facilities	Community Based Residential Treatment Facility, Mental Illness
No	323P00000X	Residential Treatment Facilities	Psychiatric Residential Treatment Facility
No	324500000X	Residential Treatment Facilities	Substance Abuse Rehabilitation Facility
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363LP0808X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Psychiatric/Mental Health	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MT	141232	Medicaid
MT	320424	Medicaid
MT	352248	Medicaid
MT	047379	Medicaid
MT	502316	Medicaid
MT	290108	Medicaid
MT	320177	Medicaid
MT	320385	Medicaid
MT	439161	Medicaid
MT	491419	Medicaid
MT	255425	Medicaid
MT	000008376	Other	PTAN
MT	601647	Medicaid
MT	439161	Medicaid