Provider Demographics
NPI:1083266993
Name:GOODLOE, MICHAELA
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:GOODLOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 E SPRING CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9828
Mailing Address - Country:US
Mailing Address - Phone:801-864-8164
Mailing Address - Fax:
Practice Address - Street 1:1040 S 500 W
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-5599
Practice Address - Country:US
Practice Address - Phone:801-864-8164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13482080-4003226000000X
UT13482080-4010225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreational Therapist Assistant
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist