Healthcare Provider Details

I. General information

NPI: 1366878977
Provider Name (Legal Business Name): ADONAI MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W 8TH ST
GILLETTE WY
82716-4108
US

IV. Provider business mailing address

707 W 8TH ST
GILLETTE WY
82716-4108
US

V. Phone/Fax

Practice location:
  • Phone: 307-685-8255
  • Fax: 888-852-8319
Mailing address:
  • Phone: 307-685-8255
  • Fax: 888-852-8319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number29650.1122
License Number StateWY

VIII. Authorized Official

Name: SUSAN P WALLA
Title or Position: NURSE PRACTITIONER
Credential: MHNP
Phone: 307-685-8255