Healthcare Provider Details

I. General information

NPI: 1144792169
Provider Name (Legal Business Name): SNAKE RIVER CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 PINE DR
JACKSON WY
83001-8417
US

IV. Provider business mailing address

PO BOX 6398
JACKSON WY
83002-6398
US

V. Phone/Fax

Practice location:
  • Phone: 307-699-3996
  • Fax:
Mailing address:
  • Phone: 307-699-3996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTORIA MENGHETTI SMITH
Title or Position: CLINICAL PSYCHOLOGIST/OWNER
Credential: PSY.D.
Phone: 307-699-3996