Healthcare Provider Details

I. General information

NPI: 1871307561
Provider Name (Legal Business Name): HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 S MAIN ST
LUSK WY
82225-5208
US

IV. Provider business mailing address

PO BOX 376
AFTON WY
83110-0376
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-2111
  • Fax:
Mailing address:
  • Phone: 307-885-9883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANNON NIZER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 307-885-9888