Healthcare Provider Details

I. General information

NPI: 1801998398
Provider Name (Legal Business Name): THOMAS BOUGSTY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 01/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 DUNN AVE
CHEYENNE WY
82001-3214
US

IV. Provider business mailing address

2321 DUNN AVE
CHEYENNE WY
82001-3214
US

V. Phone/Fax

Practice location:
  • Phone: 307-634-1480
  • Fax:
Mailing address:
  • Phone: 307-634-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberWY134
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: