Provider Demographics
| NPI: | 1912079328 |
|---|---|
| Name: | WESTERN MONTANA MENTAL HEALTH CENTER |
| Entity type: | Organization |
| Organization Name: | WESTERN MONTANA MENTAL HEALTH CENTER |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHIEF ADMINISTRATIVE OFFICER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | CORY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | DESTEIN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 406-532-8400 |
| Mailing Address - Street 1: | 1321 WYOMING ST |
| Mailing Address - Street 2: | |
| 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 - Street 2: | |
| 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 |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-11-14 |
| Last Update Date: | 2024-05-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101YA0400X, 101YP2500X, 1041C0700X, 2084P0800X, 363A00000X, 363LP0808X, 320800000X | ||
| MT | 11034 | 251B00000X, 251S00000X, 261QM0850X, 261QM0855X, 261QM0801X |
| 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) | Group - Multi-Specialty |
| 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 | 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 |
| 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 | 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 |
