Healthcare Provider Details

I. General information

NPI: 1467791293
Provider Name (Legal Business Name): QUALITY MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 RAWLINS ST
CHEYENNE WY
82001-1900
US

IV. Provider business mailing address

4025 RAWLINS ST
CHEYENNE WY
82001-1900
US

V. Phone/Fax

Practice location:
  • Phone: 307-426-4798
  • Fax: 307-426-4799
Mailing address:
  • Phone: 307-426-4798
  • Fax: 307-426-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-455
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLPC-455
License Number StateWY

VIII. Authorized Official

Name: BOB LOGAN
Title or Position: OWNER/LICENSED PROFESSIONAL COUNSEL
Credential: LPC
Phone: 307-426-4798