Healthcare Provider Details

I. General information

NPI: 1003720418
Provider Name (Legal Business Name): JUSTIN RYAN GODFREY OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
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

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

V. Phone/Fax

Practice location:
  • Phone: 435-774-8562
  • Fax:
Mailing address:
  • Phone: 435-774-8562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number14312584-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: