Healthcare Provider Details

I. General information

NPI: 1437328663
Provider Name (Legal Business Name): NORTHEAST WYOMING BOCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N MILLER AVE
GILLETTE WY
82716-2929
US

IV. Provider business mailing address

410 N MILLER AVE
GILLETTE WY
82716-2929
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-0231
  • Fax: 307-686-7628
Mailing address:
  • Phone: 307-682-0231
  • Fax: 307-686-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number124
License Number StateWY

VIII. Authorized Official

Name: LAURIE L WALSH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 307-682-0231