Provider Demographics
NPI:1295949493
Name:DANIELSON, RICH (PT MS)
Entity type:Individual
Prefix:MR
First Name:RICH
Middle Name:
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:PT MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 GREAT NORTHERN AVE APT M13
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808
Mailing Address - Country:US
Mailing Address - Phone:406-531-0043
Mailing Address - Fax:
Practice Address - Street 1:3031 S. RUSSELL
Practice Address - Street 2:SUITE #5
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803
Practice Address - Country:US
Practice Address - Phone:406-531-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000202Medicare UPIN