Healthcare Provider Details

I. General information

NPI: 1861624678
Provider Name (Legal Business Name): PRIMARY MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 WILKINGS CIRCLE
CASPER WY
82601-1336
US

IV. Provider business mailing address

301 THELMA DR PMB #464
CASPER WY
82601-2325
US

V. Phone/Fax

Practice location:
  • Phone: 307-235-9583
  • Fax: 307-265-7277
Mailing address:
  • Phone: 307-259-3467
  • Fax: 307-266-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number18154.0972
License Number StateWY

VIII. Authorized Official

Name: MRS. ROBIN MICHELLE DECASTRO
Title or Position: OWNER
Credential: APRN-BC
Phone: 307-259-3467