Healthcare Provider Details

I. General information

NPI: 1578160966
Provider Name (Legal Business Name): SMITH PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 01/08/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AIRPORT PKWY STE 240
CHEYENNE WY
82001-1542
US

IV. Provider business mailing address

1401 AIRPORT PKWY STE 240
CHEYENNE WY
82001-1542
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-7771
  • Fax: 307-632-9697
Mailing address:
  • Phone: 307-632-7771
  • Fax: 307-632-9697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAINA SMITH
Title or Position: OWNER/LICENSED PSYCHOLOGIST
Credential: PHD
Phone: 307-632-7771