Healthcare Provider Details

I. General information

NPI: 1881366912
Provider Name (Legal Business Name): THERESA GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2538 BIG HORN AVE
CODY WY
82414-9299
US

IV. Provider business mailing address

2538 BIG HORN AVE
CODY WY
82414-9299
US

V. Phone/Fax

Practice location:
  • Phone: 307-587-2197
  • Fax:
Mailing address:
  • Phone: 307-347-6165
  • Fax: 307-620-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1912
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: