Healthcare Provider Details

I. General information

NPI: 1306406509
Provider Name (Legal Business Name): KINTSUGI PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/17/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S DURBIN ST STE 108
CASPER WY
82601-2566
US

IV. Provider business mailing address

PO BOX 1117
CASPER WY
82602-1117
US

V. Phone/Fax

Practice location:
  • Phone: 307-333-5757
  • Fax: 307-439-2141
Mailing address:
  • Phone: 307-333-5757
  • Fax: 307-439-2141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATIE MADETZKE
Title or Position: PRACTICE MANAGER
Credential: CNA
Phone: 307-333-5757