Provider Demographics
NPI:1730585217
Name:GOFORTH, ANISA N (PHD, NCSP)
Entity type:Individual
Prefix:DR
First Name:ANISA
Middle Name:N
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:PHD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2534
Mailing Address - Country:US
Mailing Address - Phone:503-562-9379
Mailing Address - Fax:
Practice Address - Street 1:1444 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-0001
Practice Address - Country:US
Practice Address - Phone:406-493-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1482103T00000X
MT87674103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool