Healthcare Provider Details

I. General information

NPI: 1730608910
Provider Name (Legal Business Name): PATRICIA RUTH NESBIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S GILLETTE AVE
GILLETTE WY
82716-4205
US

IV. Provider business mailing address

601 S GILLETTE AVE
GILLETTE WY
82716-4205
US

V. Phone/Fax

Practice location:
  • Phone: 307-685-8182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAT-321
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1146
License Number StateWY

VIII. Authorized Official

Name: DAN NESBIT
Title or Position: OWNER
Credential: OFFICE MANAGER
Phone: 307-685-8182