Healthcare Provider Details

I. General information

NPI: 1083266993
Provider Name (Legal Business Name): MICHAELA GOODLOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 S 500 W
BRIGHAM CITY UT
84302-5599
US

IV. Provider business mailing address

52 E SPRING CREEK PKWY
PROVIDENCE UT
84332-9828
US

V. Phone/Fax

Practice location:
  • Phone: 801-864-8164
  • Fax:
Mailing address:
  • Phone: 801-864-8164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number13482080-4003
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number13482080-4010
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: