Healthcare Provider Details

I. General information

NPI: 1093424426
Provider Name (Legal Business Name): STEPHEN HARBOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 RAYMOND ST
GILLETTE WY
82718-6980
US

IV. Provider business mailing address

108 COLLEGE PARK CIR
GILLETTE WY
82718-9463
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-8505
  • Fax:
Mailing address:
  • Phone: 307-751-6477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAP-189
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: