Healthcare Provider Details

I. General information

NPI: 1720658842
Provider Name (Legal Business Name): PATH BEHAVIORAL HEALTH WYOMING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 MAIN ST
LANDER WY
82520-3145
US

IV. Provider business mailing address

431 MAIN ST
LANDER WY
82520-3145
US

V. Phone/Fax

Practice location:
  • Phone: 307-851-3111
  • Fax:
Mailing address:
  • Phone: 307-851-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MORGAN FALLS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 307-349-8521