Healthcare Provider Details

I. General information

NPI: 1962318733
Provider Name (Legal Business Name): MISTY DAWN STREETER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 RUSTIC RD
CODY WY
82414-7745
US

IV. Provider business mailing address

31 RUSTIC RD
CODY WY
82414-7745
US

V. Phone/Fax

Practice location:
  • Phone: 307-254-3099
  • Fax:
Mailing address:
  • Phone: 307-254-3099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: