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General NPI Number Information
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NPI Number | 1730585217
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Entity Type | Individual
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Provider Name | ANISA N GOFORTH PHD, NCSP
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Gender | Female
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Dates
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Enumeration Date | 11/11/2014
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Last Update Date | 11/11/2014
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Provider Practice Location Address
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Address Line | 1444 MANSFIELD AVE
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City | MISSOULA
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State | MT
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Zip | 59812-0001
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Country | US
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Telephone | 406-493-6471
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Fax |
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Provider Business Mailing Address
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Address Line | 619 HOWELL ST
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City | MISSOULA
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State | MT
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Zip | 59802-2534
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Country | US
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Telephone | 503-562-9379
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1482
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 87674
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License Number State | MT
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