=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770785263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY PHYSICAL THERAPY AND WELLNESS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1211 S RESERVE ST SUITE 202E
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-3101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-728-2473
-----------------------------------------------------
Fax | 406-542-6393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1211 S RESERVE ST SUITE 202E
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-3101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-728-2473
-----------------------------------------------------
Fax | 406-542-6393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER PRESIDENT
-----------------------------------------------------
Name | MRS. JUDY A LOHMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-728-2493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1515MT
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------