Healthcare Provider Details

I. General information

NPI: 1134283856
Provider Name (Legal Business Name): SHOSHONE TRIBE EARLY INTERVENTION PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 ETHETE ROAD
FT. WASHAKIE WY
82514
US

IV. Provider business mailing address

PO BOX 610
FORT WASHAKIE WY
82514-0610
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-3516
  • Fax:
Mailing address:
  • Phone: 307-332-3516
  • Fax: 307-332-9116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateWY

VIII. Authorized Official

Name: MRS. BARBARA LOCKE
Title or Position: DIRECTOR
Credential:
Phone: 30733223516