Healthcare Provider Details

I. General information

NPI: 1720401383
Provider Name (Legal Business Name): YELLOWSTONE RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 BELFRY HWY
CODY WY
82414-9524
US

IV. Provider business mailing address

137 BELFRY HWY
CODY WY
82414-9524
US

V. Phone/Fax

Practice location:
  • Phone: 307-586-3725
  • Fax:
Mailing address:
  • Phone: 307-586-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateWY
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHAWNA CHANDLER
Title or Position: DIRECTOR
Credential: LCSW
Phone: 307-586-3725