MEDICARE: MICHAELA GOODLOE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	226000000X	Recreational Therapist Assistant	13482080-4003	UT
2	225A00000X	Music Therapist	13482080-4010	UT

General Provider Information

NPI Number	:	1083266993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAELA GOODLOE

Provider Business Mailing Address
First Line	:	52 E SPRING CREEK PKWY
Second Line	:
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-9828
Country	:	US
Telephone Number	:	801-864-8164
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 S 500 W
Second Line	:
City	:	BRIGHAM CITY
State	:	UT
Zip	:	84302-5599
Country	:	US
Telephone Number	:	801-864-8164
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	04/09/2024

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Directions to “ MICHAELA GOODLOE ” Practice Location

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