Provider Demographics
NPI:1154195451
Name:MITTELSTADT, EMILY KAYELYN (SWLC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:KAYELYN
Last Name:MITTELSTADT
Suffix:
Gender:F
Credentials:SWLC
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:M
Other - Last Name:MITTELSTADT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SWLC
Mailing Address - Street 1:2620 CONNERY WAY
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2620 CONNERY WAY
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808
Practice Address - Country:US
Practice Address - Phone:406-203-9948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker