Healthcare Provider Details

I. General information

NPI: 1235108994
Provider Name (Legal Business Name): ERIC H SIITERI PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S JEFFERSON ST
CASPER WY
82601-2665
US

IV. Provider business mailing address

PO BOX 955
FORT COLLINS CO
80522-0955
US

V. Phone/Fax

Practice location:
  • Phone: 970-495-0707
  • Fax: 970-495-6885
Mailing address:
  • Phone: 970-495-0707
  • Fax: 970-495-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1816
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number278
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: