Provider Demographics
NPI:1245357177
Name:WISNIEWSKI, NADINE M (PHD)
Entity type:Individual
Prefix:MS
First Name:NADINE
Middle Name:M
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:PHD
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 1171
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-1171
Mailing Address - Country:US
Mailing Address - Phone:406-370-1727
Mailing Address - Fax:
Practice Address - Street 1:27 FORT MISSOULA RD
Practice Address - Street 2:STE B4
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7206
Practice Address - Country:US
Practice Address - Phone:406-370-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT254103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT50641OtherBLUE CROSS