Healthcare Provider Details

I. General information

NPI: 1386959575
Provider Name (Legal Business Name): EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S 400 E
SALT LAKE CITY UT
84111-2908
US

IV. Provider business mailing address

425 1ST AVE N
GREAT FALLS MT
59401-2507
US

V. Phone/Fax

Practice location:
  • Phone: 801-946-1860
  • Fax:
Mailing address:
  • Phone: 406-771-3754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MARK SHERMAN
Title or Position: CFO
Credential:
Phone: 406-771-3762