Provider Demographics
NPI:1942348875
Name:GODFREY, RYAN DON (OT CHT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DON
Last Name:GODFREY
Suffix:
Gender:M
Credentials:OT CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 EAST CENTER
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:UT
Mailing Address - Zip Code:84305-0123
Mailing Address - Country:US
Mailing Address - Phone:435-787-9030
Mailing Address - Fax:435-787-9033
Practice Address - Street 1:2310 N 400 E STE D
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1788
Practice Address - Country:US
Practice Address - Phone:435-774-8562
Practice Address - Fax:435-774-8582
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT03335214201224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3647Medicaid