Healthcare Provider Details

I. General information

NPI: 1457472748
Provider Name (Legal Business Name): HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 ADAMS ST.
AFTON WY
83110-0376
US

IV. Provider business mailing address

PO BOX 376
AFTON WY
83110-0376
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-9883
  • Fax: 307-885-5206
Mailing address:
  • Phone: 307-885-9883
  • Fax: 307-885-5206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLAT-220
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number405
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLPC-550
License Number StateWY

VIII. Authorized Official

Name: KIPP L DANA
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC-LAT
Phone: 307-885-9883