Provider Demographics
NPI:1801816640
Name:DESETH, ERIC DEAN (OT/RL)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DEAN
Last Name:DESETH
Suffix:
Gender:M
Credentials:OT/RL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 WILSON ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5094
Mailing Address - Country:US
Mailing Address - Phone:406-233-2520
Mailing Address - Fax:406-233-4062
Practice Address - Street 1:2600 WILSON ST STE 1
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5094
Practice Address - Country:US
Practice Address - Phone:406-233-2520
Practice Address - Fax:406-233-4062
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTP-OT-LIC-478225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1841474087OtherRAILROAD MEDICARE
MT1841474087OtherMEDICARE GRP NPI
MT1841474087OtherDMERC NORIDIAN MEDICARE/GRP NPI
MT1801816640Medicaid
MT1801816640Medicaid