Provider Demographics
NPI:1063439024
Name:THORMAHLEN, PAUL T (MSPT, ATC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:THORMAHLEN
Suffix:
Gender:M
Credentials:MSPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 FORT MISSOULA RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7401
Mailing Address - Country:US
Mailing Address - Phone:406-543-0617
Mailing Address - Fax:406-728-1085
Practice Address - Street 1:2831 FORT MISSOULA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7401
Practice Address - Country:US
Practice Address - Phone:406-543-0617
Practice Address - Fax:406-728-1085
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-1421225100000X
2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0342176Medicaid