Provider Demographics
NPI:1144598491
Name:BEARTOOTH PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BEARTOOTH PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DPT
Authorized Official - Phone:307-752-9335
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:BIG HORN
Mailing Address - State:WY
Mailing Address - Zip Code:82833-0306
Mailing Address - Country:US
Mailing Address - Phone:307-752-9335
Mailing Address - Fax:
Practice Address - Street 1:1333 W 5TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2752
Practice Address - Country:US
Practice Address - Phone:307-752-9335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT 1154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty