Healthcare Provider Details

I. General information

NPI: 1942348875
Provider Name (Legal Business Name): RYAN DON GODFREY OT CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 N 400 E STE D
NORTH LOGAN UT
84341-1788
US

IV. Provider business mailing address

71 EAST CENTER
CLARKSTON UT
84305-0123
US

V. Phone/Fax

Practice location:
  • Phone: 435-774-8562
  • Fax: 435-774-8582
Mailing address:
  • Phone: 435-787-9030
  • Fax: 435-787-9033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number03335214201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: