Healthcare Provider Details

I. General information

NPI: 1306419452
Provider Name (Legal Business Name): HYALITE PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WESTWOOD CIR UNIT A
BELGRADE MT
59714-2505
US

IV. Provider business mailing address

1601 WESTWOOD CIR UNIT A
BELGRADE MT
59714-2505
US

V. Phone/Fax

Practice location:
  • Phone: 406-314-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: KESHTISHA SUNDE
Title or Position: OWNER/EMPLOYEE
Credential: BCBA
Phone: 406-314-5500