Healthcare Provider Details

I. General information

NPI: 1063794394
Provider Name (Legal Business Name): HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 COUNTRY CLUB LANE
PINEDALE WY
82941-0856
US

IV. Provider business mailing address

PO BOX 856
PINEDALE WY
82941-0856
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-2111
  • Fax: 307-367-2166
Mailing address:
  • Phone: 307-367-2111
  • Fax: 307-367-2166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLAT-220
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIPP DANA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 307-885-9883