Provider Demographics
NPI:1770889727
Name:GOULET, MICHELLE LYNN
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:LYNN
Last Name:GOULET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4746
Mailing Address - Country:US
Mailing Address - Phone:701-224-9436
Mailing Address - Fax:
Practice Address - Street 1:206 N 19TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4746
Practice Address - Country:US
Practice Address - Phone:701-224-9436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND976172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND976OtherNORTH DAKOTA BOARD OF MASSAGE