Healthcare Provider Details

I. General information

NPI: 1386463420
Provider Name (Legal Business Name): WYOMING MENTAL HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MOUNTAIN VIEW CT
LANDER WY
82520-3527
US

IV. Provider business mailing address

930 MOUNTAIN VIEW CT
LANDER WY
82520-3527
US

V. Phone/Fax

Practice location:
  • Phone: 307-851-9360
  • Fax:
Mailing address:
  • Phone: 307-851-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JULIE HOUSE
Title or Position: ADMINISTRATOR
Credential:
Phone: 307-851-9360