Healthcare Provider Details

I. General information

NPI: 1003529942
Provider Name (Legal Business Name): SHAY BALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S JONES ST LOT 4
POWELL WY
82435-3103
US

IV. Provider business mailing address

333 S JONES ST LOT 4
POWELL WY
82435-3103
US

V. Phone/Fax

Practice location:
  • Phone: 307-219-8509
  • Fax:
Mailing address:
  • Phone: 307-219-8509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateWY
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateWY
# 7
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateWY
# 8
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateWY
# 9
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateWY
# 10
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number StateWY
# 11
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: