Healthcare Provider Details

I. General information

NPI: 1790071082
Provider Name (Legal Business Name): KERRIGAN GUDGEL O'CONNELL M.S. CFY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 S 3RD ST W
MISSOULA MT
59801-2241
US

IV. Provider business mailing address

1931 S 3RD ST W
MISSOULA MT
59801-2241
US

V. Phone/Fax

Practice location:
  • Phone: 406-550-3431
  • Fax:
Mailing address:
  • Phone: 406-550-3431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1293
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: