Provider Demographics
NPI:1972391415
Name:WOLFE, BONNY JEAN
Entity type:Individual
Prefix:
First Name:BONNY
Middle Name:JEAN
Last Name:WOLFE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:RONAN
Mailing Address - State:MT
Mailing Address - Zip Code:59864-0295
Mailing Address - Country:US
Mailing Address - Phone:406-203-8180
Mailing Address - Fax:
Practice Address - Street 1:414 1ST ST E STE F
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2153
Practice Address - Country:US
Practice Address - Phone:406-505-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-79239261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder