Healthcare Provider Details

I. General information

NPI: 1770889727
Provider Name (Legal Business Name): MISS MICHELLE LYNN GOULET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N 19TH ST
BISMARCK ND
58501-4746
US

IV. Provider business mailing address

206 N 19TH ST
BISMARCK ND
58501-4746
US

V. Phone/Fax

Practice location:
  • Phone: 701-224-9436
  • Fax:
Mailing address:
  • Phone: 701-224-9436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number976
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: