Basic Information
| Provider Information | |||||||||
| NPI: | 1174639199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWOLFE | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MSN PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3138 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598063138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | 4065497559 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 BANK ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065497325 | ||||||||
| FaxNumber: | 4065497559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0808X | RN16128 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000098073 | 01 | MT | BC/BS | OTHER | 890000386 | 01 | MT | RAILROAD MEDICARE | OTHER | 4300153 | 05 | MT | MEDICAID |