Healthcare Provider Details

I. General information

NPI: 1184914533
Provider Name (Legal Business Name): BIG SKY SPEECH THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SPRUCE CONE DR. UNIT 46
BIG SKY MT
59716
US

IV. Provider business mailing address

PO BOX 160694
BIG SKY MT
59716-0694
US

V. Phone/Fax

Practice location:
  • Phone: 406-209-3583
  • Fax:
Mailing address:
  • Phone: 406-209-3583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateMT

VIII. Authorized Official

Name: LISA C GOODRICH
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: MA
Phone: 406-209-3583