Healthcare Provider Details

I. General information

NPI: 1942571807
Provider Name (Legal Business Name): HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 POWDER RIVER COURT
EVANSTON WY
82930-5371
US

IV. Provider business mailing address

34 POWDER RIVER COURT
EVANSTON WY
82930-5371
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-4224
  • Fax: 307-789-4225
Mailing address:
  • Phone: 307-789-4224
  • Fax: 307-789-4225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateWY
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateWY

VIII. Authorized Official

Name: KELLY M KLEEMAN
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 307-885-9883