Healthcare Provider Details

I. General information

NPI: 1659516318
Provider Name (Legal Business Name): TETON PSYCHOLOGY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SOUTH CACHE STREET
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 3143 460 SOUTH CACHE STREET
JACKSON WY
83001-3143
US

V. Phone/Fax

Practice location:
  • Phone: 307-690-9836
  • Fax: 307-739-4522
Mailing address:
  • Phone: 307-690-9836
  • Fax: 307-739-4522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number399
License Number StateWY

VIII. Authorized Official

Name: DR. WENDY ELAINE LAAKMANN
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 307-690-9836